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Najjar E, Stålhberg M, Hage C, Ottenblad E, Manouras A, Haugen Löfman I, Lund LH. Haemodynamic effects of levosimendan in advanced but stable chronic heart failure. ESC Heart Fail 2018; 5:302-308. [PMID: 29469177 PMCID: PMC5933961 DOI: 10.1002/ehf2.12272] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2017] [Revised: 12/06/2017] [Accepted: 01/09/2018] [Indexed: 01/21/2023] Open
Abstract
AIMS Levosimendan improves haemodynamics in acute decompensated heart failure (HF). However, it is increasingly used for repetitive or intermittent infusions in advanced but stable chronic HF, without clear indication, selection criteria, or effect. We tested the hypotheses that (1) levosimendan improves haemodynamics in stable chronic HF and (2) that the response is dependent on baseline clinical and haemodynamic factors. METHODS AND RESULTS Twenty-three patients [median age 56 (49-64) years, four (17%) women] with stable New York Heart Association (NYHA) III and IV HF received a single 24 h levosimendan infusion. Non-invasive haemodynamics (inert gas re-breathing technique), estimated glomerular filtration rate, and N-terminal pro-brain natriuretic peptide were assessed before and after infusion. Levosimendan had the following effects (median change): a significant increase in cardiac output (+9.8 ± 21.6%; P = 0.026) and decrease in N-terminal pro-brain natriuretic peptide (-28.1 ± 16.3%, P < 0.001), estimated total peripheral resistance (-16.9 ± 18.3%, P = 0.005), and mean arterial pressure (-5.9 ± 8.2%, P = 0.007), but no change in estimated glomerular filtration rate (+0.89 ± 14.0%, P = 0.955). There were no significant associations between baseline clinical and/or haemodynamic factors and the levosimendan effect on cardiac output. CONCLUSIONS Levosimendan was associated with improved haemodynamics in patients with stable chronic HF, but we could not identify any predictors of the magnitude of haemodynamic response.
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Affiliation(s)
- Emil Najjar
- Department of MedicineKarolinska Institutet17177StockholmSweden
- Department of CardiologyKarolinska University Hospital17176StockholmSweden
| | - Marcus Stålhberg
- Department of MedicineKarolinska Institutet17177StockholmSweden
- Department of CardiologyKarolinska University Hospital17176StockholmSweden
| | - Camilla Hage
- Department of MedicineKarolinska Institutet17177StockholmSweden
- Department of CardiologyKarolinska University Hospital17176StockholmSweden
| | - Erica Ottenblad
- Department of CardiologyKarolinska University Hospital17176StockholmSweden
| | - Aristomenis Manouras
- Department of MedicineKarolinska Institutet17177StockholmSweden
- Department of CardiologyKarolinska University Hospital17176StockholmSweden
| | - Ida Haugen Löfman
- Department of MedicineKarolinska Institutet17177StockholmSweden
- Department of CardiologyKarolinska University Hospital17176StockholmSweden
| | - Lars H. Lund
- Department of MedicineKarolinska Institutet17177StockholmSweden
- Department of CardiologyKarolinska University Hospital17176StockholmSweden
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52
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Sieweke JT, Pfeffer TJ, Berliner D, König T, Hallbaum M, Napp LC, Tongers J, Kühn C, Schmitto JD, Hilfiker-Kleiner D, Schäfer A, Bauersachs J. Cardiogenic shock complicating peripartum cardiomyopathy: Importance of early left ventricular unloading and bromocriptine therapy. EUROPEAN HEART JOURNAL-ACUTE CARDIOVASCULAR CARE 2018; 9:173-182. [PMID: 29792513 DOI: 10.1177/2048872618777876] [Citation(s) in RCA: 36] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
INTRODUCTION Acute peripartum cardiomyopathy complicated by cardiogenic shock is a rare but life-threatening disease. A prolactin fragment is considered causal for the pathogenesis of peripartum cardiomyopathy. This analysis sought to investigate the role of early percutaneous mechanical circulatory support with micro-axial flow-pumps and/or veno-arterial extracorporeal membrane oxygenation in combination with the prolactin inhibitor bromocriptine in refractory cardiogenic shock complicating peripartum cardiomyopathy. METHODS AND RESULTS In this single-centre analysis, five peripartum cardiomyopathy patients with refractory cardiogenic shock received mechanical circulatory support with either Impella CP microaxial pump only (n=2) or in combination with veno-arterial extracorporeal membrane oxygenation (n=3) in the setting of biventricular failure. All patients were mechanically ventilated. In all cases mechanical circulatory support was combined with bromocriptine therapy and early administration of levosimendan. All patients survived the acute phase of refractory cardiogenic shock. Mechanical circulatory support using a micro-axial pump allowed to significantly reduce catecholamine dosage. Remarkably, early left ventricular support with micro-axial flow-pumps resulted in myocardial recovery whereas delayed Impella (mechanical circulatory support) implantation was associated with poor left ventricular recovery. CONCLUSION Mechanical circulatory support in patients with refractory cardiogenic shock complicating peripartum cardiomyopathy was associated with a 30-day survival of 100% and a favourable outcome. Notably, early left ventricular unloading combined with bromocriptine therapy was associated with left ventricular recovery. Therefore, an immediate transfer to a tertiary hospital experienced in mechanical circulatory support in combination with bromocriptine treatment seems indispensable for successful treatment of peripartum cardiomyopathy complicated by cardiogenic shock.
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Affiliation(s)
| | | | - Dominik Berliner
- Department of Cardiology and Angiology, Hannover Medical School, Germany
| | - Tobias König
- Department of Cardiology and Angiology, Hannover Medical School, Germany
| | | | - L Christian Napp
- Department of Cardiology and Angiology, Hannover Medical School, Germany
| | - Jörn Tongers
- Department of Cardiology and Angiology, Hannover Medical School, Germany
| | - Christian Kühn
- Department of Cardiothoracic, Transplant and Vascular Surgery, Hannover Medical School, Germany
| | - Jan D Schmitto
- Department of Cardiothoracic, Transplant and Vascular Surgery, Hannover Medical School, Germany
| | | | - Andreas Schäfer
- Department of Cardiology and Angiology, Hannover Medical School, Germany
| | - Johann Bauersachs
- Department of Cardiology and Angiology, Hannover Medical School, Germany
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53
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Coiro S, Carluccio E, Biagioli P, Alunni G, Murrone A, D'Antonio A, Zuchi C, Mengoni A, Girerd N, Borghi C, Ambrosio G. Elevated serum uric acid concentration at discharge confers additive prognostic value in elderly patients with acute heart failure. Nutr Metab Cardiovasc Dis 2018; 28:361-368. [PMID: 29501446 DOI: 10.1016/j.numecd.2017.12.009] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/11/2017] [Revised: 12/13/2017] [Accepted: 12/24/2017] [Indexed: 12/22/2022]
Abstract
BACKGROUND AND AIMS Elevated serum uric acid (sUA) concentrations have been associated with worse prognosis in heart failure (HF) but little is known about elderly patients. We aimed to assess long-term additive prognostic value of sUA in elderly patients hospitalized for HF. METHODS AND RESULTS Clinical and echocardiographic characteristics of 310 consecutive elderly patients hospitalized for HF were collected. During index period, 206 had sUA concentrations available, which were obtained within 24 h prior to discharge; 10 patients were lost to follow-up, leaving 196 patients available. Patients had a median age of 77 (IQR 69-83) years, and were mostly male (64.5%). sUA ranges for tertiles I-III were: 1.5-6.1, 6.2-8.3, and 8.4-18.9 mg/dl, respectively. During a median follow-up of 27 months (IQR 10.5-39.5), 122 combined events occurred (87 deaths and 73 HF rehospitalizations). Four-year event-free survival for the combined endpoint was 46 ± 7% for tertile I, 34 ± 7% for tertile II, and 21 ± 5% for tertile III (P = 0.001). By multivariable Cox backward analysis, sUA was retained as a significant predictor. Compared with the lowest sUA tertile, tertile III showed a strong association with outcome, also after adjustment for other predictors (HR 1.84, 95% CI 1.16-2.93; P = 0.01). Importantly, addition of sUA to the other significant predictors of outcome resulted in improved risk classification (net reclassification improvement 0.19, P = 0.017). CONCLUSIONS High sUA at discharge is a strong predictor of adverse outcome in elderly hospitalized for HF, and it significantly improves risk classification. Measuring sUA can be a simple and useful tool to identify high-risk elderly hospitalized for HF.
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Affiliation(s)
- S Coiro
- Division of Cardiology, University of Perugia, School of Medicine, Perugia, Italy
| | - E Carluccio
- Division of Cardiology, University of Perugia, School of Medicine, Perugia, Italy
| | - P Biagioli
- Division of Cardiology, University of Perugia, School of Medicine, Perugia, Italy
| | - G Alunni
- Division of Cardiology, University of Perugia, School of Medicine, Perugia, Italy
| | - A Murrone
- Division of Cardiology, University of Perugia, School of Medicine, Perugia, Italy
| | - A D'Antonio
- Division of Cardiology, University of Perugia, School of Medicine, Perugia, Italy
| | - C Zuchi
- Division of Cardiology, University of Perugia, School of Medicine, Perugia, Italy
| | - A Mengoni
- Division of Cardiology, University of Perugia, School of Medicine, Perugia, Italy
| | - N Girerd
- INSERM, Centre d'Investigations Cliniques 9501, Université de Lorraine, CHU de Nancy, Institut Lorrain du cœur et des vaisseaux, Nancy, France
| | - C Borghi
- Department of Medical and Surgical Sciences, University of Bologna, Bologna, Italy
| | - G Ambrosio
- Division of Cardiology, University of Perugia, School of Medicine, Perugia, Italy.
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Levosimendan: new indications and evidence for reduction in perioperative mortality? Curr Opin Anaesthesiol 2018; 29:454-61. [PMID: 27168089 DOI: 10.1097/aco.0000000000000357] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
PURPOSE OF REVIEW In the last years, the perioperative use of levosimendan in cardiac surgery patients is spreading. Moreover, newer indications have been suggested such as the treatment of sepsis-associated myocardial dysfunction. In the present review, we discuss the most recent evidences in these settings. RECENT FINDINGS Levosimendan has been seemingly confirmed to reduce mortality in patients undergoing cardiac surgery. In particular, it appears to be the only inotropic drug to have a favorable effect on survival in any clinical setting. Moreover, levosimendan has been shown to exert a cardioprotective action and to reduce acute kidney injury, renal replacement therapy, and ICU stay in cardiac surgery patients. Finally, levosimendan has been suggested to reduce mortality in patients with severe sepsis and to improve renal outcomes in critically ill patients. SUMMARY Although a strong rationale likely exists to use levosimendan in the setting of perioperative and critical care medicine, evidence mainly comes from small and often poor-quality randomized clinical trials, whose results acquire significance only when pooled in meta-analyses. Moreover, some aspects related to which subgroups of patients may derive the most benefits from receiving levosimendan, to the optimal timing of administration, and to the potential adverse effects need to be further clarified. Important insights will be hopefully provided soon by the several large multicenter investigations which are currently ongoing.
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55
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Schumann J, Henrich EC, Strobl H, Prondzinsky R, Weiche S, Thiele H, Werdan K, Frantz S, Unverzagt S. Inotropic agents and vasodilator strategies for the treatment of cardiogenic shock or low cardiac output syndrome. Cochrane Database Syst Rev 2018; 1:CD009669. [PMID: 29376560 PMCID: PMC6491099 DOI: 10.1002/14651858.cd009669.pub3] [Citation(s) in RCA: 50] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
BACKGROUND Cardiogenic shock (CS) and low cardiac output syndrome (LCOS) as complications of acute myocardial infarction (AMI), heart failure (HF) or cardiac surgery are life-threatening conditions. While there is a broad body of evidence for the treatment of people with acute coronary syndrome under stable haemodynamic conditions, the treatment strategies for people who become haemodynamically unstable or develop CS remain less clear. We have therefore summarised here the evidence on the treatment of people with CS or LCOS with different inotropic agents and vasodilative drugs. This is the first update of a Cochrane review originally published in 2014. OBJECTIVES To assess efficacy and safety of cardiac care with positive inotropic agents and vasodilator strategies in people with CS or LCOS due to AMI, HF or cardiac surgery. SEARCH METHODS We searched CENTRAL, MEDLINE, Embase and CPCI-S Web of Science in June 2017. We also searched four registers of ongoing trials and scanned reference lists and contacted experts in the field to obtain further information. No language restrictions were applied. SELECTION CRITERIA Randomised controlled trials in people with myocardial infarction, heart failure or cardiac surgery complicated by cardiogenic shock or LCOS. DATA COLLECTION AND ANALYSIS We used standard methodological procedures expected by Cochrane. MAIN RESULTS We identified 13 eligible studies with 2001 participants (mean or median age range 58 to 73 years) and two ongoing studies. We categorised studies into eight comparisons, all against cardiac care and additional other active drugs or placebo. These comparisons investigated the efficacy of levosimendan versus dobutamine, enoximone or placebo, epinephrine versus norepinephrine-dobutamine, amrinone versus dobutamine, dopexamine versus dopamine, enoximone versus dopamine and nitric oxide versus placebo.All trials were published in peer-reviewed journals, and analysis was done by the intention-to-treat (ITT) principle. Twelve of 13 trials were small with few included participants. Acknowledgement of funding by the pharmaceutical industry or missing conflict of interest statements emerged in five of 13 trials. In general, confidence in the results of analysed studies was reduced due to serious study limitations, very serious imprecision or indirectness. Domains of concern, which show a high risk of more than 50%, include performance bias (blinding of participants and personnel) and bias affecting the quality of evidence on adverse events.Levosimendan may reduce short-term mortality compared to a therapy with dobutamine (RR 0.60, 95% CI 0.37 to 0.95; 6 studies; 1776 participants; low-quality evidence; NNT: 16 (patients with moderate risk), NNT: 5 (patients with CS)). This initial short-term survival benefit with levosimendan vs. dobutamine is not confirmed on long-term follow up. There is uncertainty (due to lack of statistical power) as to the effect of levosimendan compared to therapy with placebo (RR 0.48, 95% CI 0.12 to 1.94; 2 studies; 55 participants, very low-quality evidence) or enoximone (RR 0.50, 95% CI 0.22 to 1.14; 1 study; 32 participants, very low-quality evidence).All comparisons comparing other positive inotropic, inodilative or vasodilative drugs presented uncertainty on their effect on short-term mortality with very low-quality evidence and based on only one RCT. These single studies compared epinephrine with norepinephrine-dobutamine (RR 1.25, 95% CI 0.41 to 3.77; 30 participants), amrinone with dobutamine (RR 0.33, 95% CI 0.04 to 2.85; 30 participants), dopexamine with dopamine (no in-hospital deaths from 70 participants), enoximone with dobutamine (two deaths from 40 participants) and nitric oxide with placebo (one death from three participants). AUTHORS' CONCLUSIONS Apart from low quality of evidence data suggesting a short-term mortality benefit of levosimendan compared with dobutamine, at present there are no robust and convincing data to support a distinct inotropic or vasodilator drug-based therapy as a superior solution to reduce mortality in haemodynamically unstable people with cardiogenic shock or LCOS.Considering the limited evidence derived from the present data due to a generally high risk of bias and imprecision, it should be emphasised that there remains a great need for large, well-designed randomised trials on this topic to close the gap between daily practice in critical care medicine and the available evidence. It seems to be useful to apply the concept of 'early goal-directed therapy' in cardiogenic shock and LCOS with early haemodynamic stabilisation within predefined timelines. Future clinical trials should therefore investigate whether such a therapeutic concept would influence survival rates much more than looking for the 'best' drug for haemodynamic support.
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Affiliation(s)
- Julia Schumann
- Martin‐Luther‐University Halle‐WittenbergDepartment of Anaesthesiology and Surgical Intensive CareHalle/SaaleGermany
| | - Eva C Henrich
- Martin‐Luther‐University Halle‐WittenbergInstitute of Medical Epidemiology, Biostatistics and InformaticsHalle/SaaleGermany06112
| | - Hellen Strobl
- Martin‐Luther‐University Halle‐WittenbergInstitute of Medical Epidemiology, Biostatistics and InformaticsHalle/SaaleGermany06112
| | - Roland Prondzinsky
- Carl von Basedow Klinikum MerseburgCardiology/Intensive Care MedicineWeisse Mauer 42MerseburgGermany06217
| | - Sophie Weiche
- Martin‐Luther‐University Halle‐WittenbergDepartment of Internal Medicine IIIHalle/SaaleGermany
| | - Holger Thiele
- University Clinic Schleswig‐Holstein, Campus LübeckMedical Clinic II (Kardiology, Angiology, Intensive Care Medicine)Ratzeburger Allee 160LubeckD‐23538Germany
| | - Karl Werdan
- Martin‐Luther‐University Halle‐WittenbergDepartment of Internal Medicine IIIHalle/SaaleGermany
| | - Stefan Frantz
- Martin‐Luther‐University Halle‐WittenbergDepartment of Internal Medicine IIIHalle/SaaleGermany
| | - Susanne Unverzagt
- Martin‐Luther‐University Halle‐WittenbergInstitute of Medical Epidemiology, Biostatistics and InformaticsHalle/SaaleGermany06112
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Sato R, Nasu M. Time to re-think the use of dobutamine in sepsis. J Intensive Care 2017; 5:65. [PMID: 29201378 PMCID: PMC5699177 DOI: 10.1186/s40560-017-0264-6] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2017] [Accepted: 11/17/2017] [Indexed: 12/30/2022] Open
Abstract
Dobutamine is commonly used worldwide and included in the protocol for early goal-directed therapy (EGDT). Since the use of dobutamine in EGDT was reported, it has been considered to be an important component, especially in the treatment of septic patients with myocardial dysfunction. However, it is questionable whether dobutamine improves the mortality of sepsis and septic shock. In three recent randomized controlled trials (ProCESS, ProMISe, and ARISE trials), the frequency of dobutamine use was significantly higher in the EGDT group than in the standard care group, but there were no significant differences in the mortality between the groups. These results suggested that dobutamine use may have been overemphasized despite its insignificant effect on the mortality in septic patients. Further, a propensity score analysis revealed that dobutamine use was associated with higher mortality in patients with septic shock. Although dobutamine leads to an increase in cardiac index, myocardial oxygen demand also increases, thus increasing the risk of myocardial ischemia and tachyarrhythmia. It is well known that the mortality in sepsis complicated with atrial fibrillation (AFib) is worse than that in sepsis without AFib. A propensity score-matched analysis reported that β-blockers were associated with better survival in patients with sepsis complicated with AFib. Further, a randomized controlled trial reported that a short-acting β-blocker improved the survival in patients with septic shock. These studies also indicated the risk of β-stimulation during sepsis. Notably, improvements in surrogate markers, such as CI, do not always indicate improvements in patient-centered outcomes, such as mortality. Conversely, some evidence indicates the worsening of patient-centered outcomes despite improvements in surrogate markers. Thus, available evidence suggests that the benefits of dobutamine in patients with sepsis are unclear, but its use might be harmful rather than beneficial, considering the beneficial effects of β-blockers in sepsis that have been reported in recent clinical studies. From this perspective, we will soon have to rethink regarding dobutamine use in patients with sepsis.
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Affiliation(s)
- Ryota Sato
- Department of Emergency and Critical Care Medicine, Urasoe General Hospital, Okinawa, Japan.,Department of Internal Medicine, John A. Burns School of Medicine, University of Hawaii at Manoa, 1356 Lusitana Street, 7th Floor, Honolulu, HI 96813 USA
| | - Michitaka Nasu
- Department of Emergency and Critical Care Medicine, Urasoe General Hospital, Okinawa, Japan
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Forestieri P, Bolzan DW, Santos VB, Moreira RSL, de Almeida DR, Trimer R, de Souza Brito F, Borghi-Silva A, de Camargo Carvalho AC, Arena R, Gomes WJ, Guizilini S. Neuromuscular electrical stimulation improves exercise tolerance in patients with advanced heart failure on continuous intravenous inotropic support use-randomized controlled trial. Clin Rehabil 2017. [PMID: 28633534 DOI: 10.1177/0269215517715762] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
OBJECTIVE To evaluate the impact of a short-term neuromuscular electrical stimulation program on exercise tolerance in hospitalized patients with advanced heart failure who have suffered an acute decompensation and are under continuous intravenous inotropic support. DESIGN A randomized controlled study. SUBJECTS Initially, 195 patients hospitalized for decompensated heart failure were recruited, but 70 were randomized. INTERVENTION Patients were randomized into two groups: control group subject to the usual care ( n = 35); neuromuscular electrical stimulation group ( n = 35) received daily training sessions to both lower extremities for around two weeks. MAIN MEASURES The baseline 6-minute walk test to determine functional capacity was performed 24 hours after hospital admission, and intravenous inotropic support dose was daily checked in all patients. The outcomes were measured in two weeks or at the discharge if the patients were sent back home earlier than two weeks. RESULTS After losses of follow-up, a total of 49 patients were included and considered for final analysis (control group, n = 25 and neuromuscular electrical stimulation group, n = 24). The neuromuscular electrical stimulation group presented with a higher 6-minute walk test distance compared to the control group after the study protocol (293 ± 34.78 m vs. 265.8 ± 48.53 m, P < 0.001, respectively). Neuromuscular electrical stimulation group also demonstrated a significantly higher dose reduction of dobutamine compared to control group after the study protocol (2.72 ± 1.72 µg/kg/min vs. 3.86 ± 1.61 µg/kg/min, P = 0.001, respectively). CONCLUSION A short-term inpatient neuromuscular electrical stimulation rehabilitation protocol improved exercise tolerance and reduced intravenous inotropic support necessity in patients with advanced heart failure suffering a decompensation episode.
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Affiliation(s)
- Patrícia Forestieri
- 1 Cardiology and Cardiovascular Surgery Discipline, Sao Paulo Hospital, Federal University of Sao Paulo, São Paulo, Brazil
| | - Douglas W Bolzan
- 1 Cardiology and Cardiovascular Surgery Discipline, Sao Paulo Hospital, Federal University of Sao Paulo, São Paulo, Brazil
| | - Vinícius B Santos
- 1 Cardiology and Cardiovascular Surgery Discipline, Sao Paulo Hospital, Federal University of Sao Paulo, São Paulo, Brazil
| | - Rita Simone Lopes Moreira
- 1 Cardiology and Cardiovascular Surgery Discipline, Sao Paulo Hospital, Federal University of Sao Paulo, São Paulo, Brazil
| | - Dirceu Rodrigues de Almeida
- 1 Cardiology and Cardiovascular Surgery Discipline, Sao Paulo Hospital, Federal University of Sao Paulo, São Paulo, Brazil
| | - Renata Trimer
- 2 Cardiopulmonary Physiotherapy Laboratory, Federal University of São Carlos, São Carlos, Brazil
| | - Flávio de Souza Brito
- 1 Cardiology and Cardiovascular Surgery Discipline, Sao Paulo Hospital, Federal University of Sao Paulo, São Paulo, Brazil
| | - Audrey Borghi-Silva
- 2 Cardiopulmonary Physiotherapy Laboratory, Federal University of São Carlos, São Carlos, Brazil
| | | | - Ross Arena
- 3 Department of Physical Therapy, College of Applied Health Sciences, University of Illinois at Chicago, Chicago, IL, USA
| | - Walter J Gomes
- 1 Cardiology and Cardiovascular Surgery Discipline, Sao Paulo Hospital, Federal University of Sao Paulo, São Paulo, Brazil
| | - Solange Guizilini
- 1 Cardiology and Cardiovascular Surgery Discipline, Sao Paulo Hospital, Federal University of Sao Paulo, São Paulo, Brazil.,4 Department of Human Motion Sciences, Physiotherapy School, Federal University of São Paulo, Sao Paulo, Brazil
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58
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Lorenz K, Rosner MR, Brand T, Schmitt JP. Raf kinase inhibitor protein: lessons of a better way for β-adrenergic receptor activation in the heart. J Physiol 2017; 595:4073-4087. [PMID: 28444807 PMCID: PMC5471367 DOI: 10.1113/jp274064] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2017] [Accepted: 02/27/2017] [Indexed: 12/13/2022] Open
Abstract
Stimulation of β-adrenergic receptors (βARs) provides the most efficient physiological mechanism to enhance contraction and relaxation of the heart. Activation of βARs allows rapid enhancement of myocardial function in order to fuel the muscles for running and fighting in a fight-or-flight response. Likewise, βARs become activated during cardiovascular disease in an attempt to counteract the restrictions of cardiac output. However, long-term stimulation of βARs increases the likelihood of cardiac arrhythmias, adverse ventricular remodelling, decline of cardiac performance and premature death, thereby limiting the use of βAR agonists in the treatment of heart failure. Recently the endogenous Raf kinase inhibitor protein (RKIP) was found to activate βAR signalling of the heart without adverse effects. This review will summarize the current knowledge on RKIP-driven compared to receptor-mediated signalling in cardiomyocytes. Emphasis is given to the differential effects of RKIP on β1 - and β2 -ARs and their downstream targets, the regulation of myocyte calcium cycling and myofilament activity.
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Affiliation(s)
- Kristina Lorenz
- Comprehensive Heart Failure CenterUniversity of WürzburgVersbacher Straße 997078WürzburgGermany
- West German Heart and Vascular Center EssenUniversity Hospital EssenHufelandstraße 5545147EssenGermany
- Leibniz‐Institut für Analytische Wissenschaften – ISAS – e.V.Bunsen‐Kirchhoff‐Straße 1144139DortmundGermany
- Institute of Pharmacology and ToxicologyUniversity of WürzburgVersbacher Straße 997078WürzburgGermany
| | - Marsha Rich Rosner
- Ben May Department for Cancer ResearchUniversity of ChicagoChicagoIL 60637USA
| | - Theresa Brand
- Leibniz‐Institut für Analytische Wissenschaften – ISAS – e.V.Bunsen‐Kirchhoff‐Straße 1144139DortmundGermany
- Institute of Pharmacology and ToxicologyUniversity of WürzburgVersbacher Straße 997078WürzburgGermany
| | - Joachim P Schmitt
- Institute of Pharmacology and Clinical PharmacologyDüsseldorf University HospitalUniverstitätsstraße 140225DüsseldorfGermany
- Cardiovascular Research Institute Düsseldorf (CARID)Heinrich‐Heine‐UniversityUniverstitätsstraße 140225DüsseldorfGermany
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59
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Harjola VP, Mullens W, Banaszewski M, Bauersachs J, Brunner-La Rocca HP, Chioncel O, Collins SP, Doehner W, Filippatos GS, Flammer AJ, Fuhrmann V, Lainscak M, Lassus J, Legrand M, Masip J, Mueller C, Papp Z, Parissis J, Platz E, Rudiger A, Ruschitzka F, Schäfer A, Seferovic PM, Skouri H, Yilmaz MB, Mebazaa A. Organ dysfunction, injury and failure in acute heart failure: from pathophysiology to diagnosis and management. A review on behalf of the Acute Heart Failure Committee of the Heart Failure Association (HFA) of the European Society of Cardiology (ESC). Eur J Heart Fail 2017; 19:821-836. [PMID: 28560717 DOI: 10.1002/ejhf.872] [Citation(s) in RCA: 239] [Impact Index Per Article: 34.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/07/2016] [Revised: 03/20/2017] [Accepted: 04/04/2017] [Indexed: 12/18/2022] Open
Abstract
Organ injury and impairment are commonly observed in patients with acute heart failure (AHF), and congestion is an essential pathophysiological mechanism of impaired organ function. Congestion is the predominant clinical profile in most patients with AHF; a smaller proportion presents with peripheral hypoperfusion or cardiogenic shock. Hypoperfusion further deteriorates organ function. The injury and dysfunction of target organs (i.e. heart, lungs, kidneys, liver, intestine, brain) in the setting of AHF are associated with increased risk for mortality. Improvement in organ function after decongestive therapies has been associated with a lower risk for post-discharge mortality. Thus, the prevention and correction of organ dysfunction represent a therapeutic target of interest in AHF and should be evaluated in clinical trials. Treatment strategies that specifically prevent, reduce or reverse organ dysfunction remain to be identified and evaluated to determine if such interventions impact mortality, morbidity and patient-centred outcomes. This paper reflects current understanding among experts of the presentation and management of organ impairment in AHF and suggests priorities for future research to advance the field.
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Affiliation(s)
- Veli-Pekka Harjola
- Emergency Medicine, University of Helsinki, Helsinki University Hospital, Helsinki, Finland
| | - Wilfried Mullens
- Department of Cardiology, Ziekenhuis Oost Limburg, Genk, Belgium.,Biomedical Research Institute, Faculty of Medicine and Life Sciences, Hasselt University, Diepenbeek, Belgium
| | - Marek Banaszewski
- Intensive Cardiac Therapy Clinic, Institute of Cardiology, Warsaw, Poland
| | - Johann Bauersachs
- Department of Cardiology and Angiology, Medical School Hannover, Hannover, Germany
| | | | - Ovidiu Chioncel
- Institute of Emergency in Cardiovascular Disease, University of Medicine Carol Davila, Bucharest, Romania
| | - Sean P Collins
- Department of Emergency Medicine, Vanderbilt University Medical Centre, Nashville, TN, USA
| | - Wolfram Doehner
- Centre for Stroke Research, Berlin, Germany.,Department of Cardiology, Charité Medical University, Berlin, Germany
| | - Gerasimos S Filippatos
- National and Kapodistrian University of Athens, School of Medicine, Athens University Hospital Attikon, Athens, Greece
| | - Andreas J Flammer
- University Heart Centre, University Hospital Zurich, Zurich, Switzerland
| | - Valentin Fuhrmann
- Division of Gastroenterology and Hepatology, Medical University of Vienna, Vienna, Austria.,Department of Intensive Care Medicine, University Medical Centre Hamburg-Eppendorf, Hamburg, Germany
| | - Mitja Lainscak
- Department of Internal Medicine, General Hospital Murska Sobota, Murska Sobota, Slovenia.,Department of Research and Education, General Hospital Murska Sobota, Murska Sobota, Slovenia.,Faculty of Medicine, University of Ljubljana, Ljubljana, Slovenia
| | - Johan Lassus
- Cardiology, University of Helsinki, Helsinki University Hospital, Helsinki, Finland
| | - Matthieu Legrand
- U942 Inserm, Assistance Publique-Hôpitaux de Paris (AP-HP), Paris, France.,Investigation Network Initiative Cardiovascular and Renal Clinical Trialists (INI-CRCT), Nancy, France.,Department of Anaesthesiology, Critical Care and Burn Unit, St Louis Hospital, University Paris Denis Diderot, Paris, France
| | - Josep Masip
- Consorci Sanitari Integral (Public Health Consortium), University of Barcelona, Barcelona, Spain.,Department of Cardiology, Hospital Sanitas CIMA, Barcelona, Spain
| | - Christian Mueller
- Department of Cardiology, University Hospital Basel, Basel, Switzerland.,Cardiovascular Research Institute Basel (CRIB), University Hospital Basel, Basel, Switzerland
| | - Zoltán Papp
- Division of Clinical Physiology, Department of Cardiology, Research Centre for Molecular Medicine, Faculty of Medicine, University of Debrecen, Debrecen, Hungary
| | - John Parissis
- National and Kapodistrian University of Athens, School of Medicine, Athens University Hospital Attikon, Athens, Greece
| | - Elke Platz
- Department of Emergency Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Alain Rudiger
- Cardio-Surgical Intensive Care Unit, University Hospital Zurich, University of Zurich, Zurich, Switzerland
| | - Frank Ruschitzka
- University Heart Centre, University Hospital Zurich, Zurich, Switzerland
| | - Andreas Schäfer
- Department of Cardiology and Angiology, Medical School Hannover, Hannover, Germany
| | - Petar M Seferovic
- Department of Internal Medicine, Belgrade University School of Medicine, Belgrade, Serbia.,Heart Failure Centre, Belgrade University Medical Centre, Belgrade, Serbia
| | - Hadi Skouri
- Division of Cardiology, Department of Internal Medicine, American University of Beirut Medical Centre, Beirut, Lebanon
| | - Mehmet Birhan Yilmaz
- Department of Cardiology, Faculty of Medicine, Cumhuriyet University, Sivas, Turkey
| | - Alexandre Mebazaa
- U942 Inserm, Assistance Publique-Hôpitaux de Paris (AP-HP), Paris, France.,Investigation Network Initiative Cardiovascular and Renal Clinical Trialists (INI-CRCT), Nancy, France.,University Paris Diderot, Paris, France.,Department of Anaesthesia and Critical Care, University Hospitals Saint Louis-Lariboisière, Paris, France
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60
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Oras J, Redfors B, Ali A, Alkhoury J, Seeman-Lodding H, Omerovic E, Ricksten SE. Early treatment with isoflurane attenuates left ventricular dysfunction and improves survival in experimental Takotsubo. Acta Anaesthesiol Scand 2017; 61:399-407. [PMID: 28185263 DOI: 10.1111/aas.12861] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2016] [Revised: 11/28/2016] [Accepted: 01/04/2017] [Indexed: 01/03/2023]
Abstract
BACKGROUND Takotsubo syndrome (TS) is an acute cardiac condition, often triggered by critical illness, for which no specific treatment exists. Previously, we showed that isoflurane can prevent experimental TS. The aim of this study was to evaluate the potential treatment effects of isoflurane. Our primary hypothesis was that early treatment with isoflurane attenuates left ventricular akinesia in experimental TS. METHOD In propofol-sedated animals, TS was induced by an intraperitoneal bolus of isoprenaline (50 mg/kg). Animals were randomized to one of six groups (n = 15 in each group), and 1% isoflurane was administered for 90 min in all groups. Isoflurane treatment was started at 0, 10, 30 (early treatment) or 120 (late treatment) minutes after isoprenaline injection. One additional late treatment group received isoflurane 0.5% for 180 min. A control group did not receive isoflurane. Left ventricular (LV) echocardiographic examination was performed at 90 min and 48 h after isoprenaline. Mortality was assessed at 48 h. RESULTS Median degree of LV akinesia at 90 min was 24% in the control group and 0% in the early treatment groups (P < 0.001). Stroke volume, cardiac output and LV ejection fraction were higher in the early treatment groups vs. controls (P < 0.01). Mortality was lower in the early treatment groups (24%) vs. controls (86%) (P < 0.001). Mortality did not differ between the late treatment groups and controls. CONCLUSION Early treatment with isoflurane attenuates the LV akinesia and improves survival in experimental TS. Isoflurane sedation in patients at risk of developing Takotsubo syndrome could be a subject for future studies.
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Affiliation(s)
- J. Oras
- The Department of Anaesthesiology and Intensive Care Medicine; Institute of Clinical Sciences; Sahlgrenska Academy; University of Gothenburg; Gothenburg Sweden
| | - B. Redfors
- Department of Cardiology; Sahlgrenska Academy; University of Gothenburg; Gothenburg Sweden
- Department of Molecular and Clinical Medicine; Wallenberg Laboratory; Institute of Medicine; Sahlgrenska Academy; University of Gothenburg; Gothenburg Sweden
| | - A. Ali
- Department of Molecular and Clinical Medicine; Wallenberg Laboratory; Institute of Medicine; Sahlgrenska Academy; University of Gothenburg; Gothenburg Sweden
| | - J. Alkhoury
- Department of Molecular and Clinical Medicine; Wallenberg Laboratory; Institute of Medicine; Sahlgrenska Academy; University of Gothenburg; Gothenburg Sweden
| | - H. Seeman-Lodding
- The Department of Anaesthesiology and Intensive Care Medicine; Institute of Clinical Sciences; Sahlgrenska Academy; University of Gothenburg; Gothenburg Sweden
| | - E. Omerovic
- Department of Cardiology; Sahlgrenska Academy; University of Gothenburg; Gothenburg Sweden
- Department of Molecular and Clinical Medicine; Wallenberg Laboratory; Institute of Medicine; Sahlgrenska Academy; University of Gothenburg; Gothenburg Sweden
| | - S.-E. Ricksten
- The Department of Anaesthesiology and Intensive Care Medicine; Institute of Clinical Sciences; Sahlgrenska Academy; University of Gothenburg; Gothenburg Sweden
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Nesiritide Therapy Is Associated With Better Clinical Outcomes Than Dobutamine Therapy in Heart Failure. Am J Ther 2017; 24:e181-e188. [PMID: 26164026 DOI: 10.1097/mjt.0000000000000278] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
Abstract
To evaluate the therapeutic effects of dobutamine and nesiritide in the treatment of heart failure (HF), a meta-analysis of published studies was conducted. Computerized bibliographic databases in Chinese and English languages were carefully searched to identify the relevant literature. A total of 6 cohort studies were enrolled in current meta-analysis for statistical analyses. The effect of dobutamine and nesiritide in patients with HF was estimated by odds ratios (ORs) and 95% confidence interval (CI). Our results revealed a significantly higher survival rate in nesiritide-treated patients, compared with those treated with dobutamine (OR = 1.97; 95% CI, 1.43-2.71; P < 0.001). In addition, a lower readmission rate was also associated with the nesiritide-treated group in comparison with the dobutamine-treated group (OR = 1.96; 95% CI, 1.39-2.78; P < 0.001). A stratified analysis revealed that the subgroup of patients with HF treated with nesiritide showed higher survival outcomes than those patients with HF treated with dobutamine when follow-up period was greater than 6 months (OR = 1.70; 95% CI, 1.21-2.38; P = 0.002) but not under 6 months (P > 0.05). This indicated that nesiritide treatment had longer term benefits as well. Interestingly, based on the reason for readmission, a subgroup analysis of the HF subgroup and the "all-cause" subgroup showed that higher readmission rates were associated with dobutamine treatment in both subgroups (HF: OR = 2.71; 95% CI, = 1.51-4.83; P = 0.001; all-cause: OR = 1.64; 95% CI, 1.06-2.53; P = 0.026; respectively). Our results suggest that nesiritide therapy is associated with a lower in-hospital mortality rates and decreased readmission rates compared with dobutamine treatment in patients with HF.
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Abstract
Takotsubo syndrome (TS) is characterized by severe reversible left ventricular (LV) wall motion abnormality in the absence of explanatory coronary lesion. Despite an increasing number of patients diagnosed with TS worldwide, there are no randomized clinical trials. In mild cases, no treatment or a short course of limited anticoagulation therapy may be sufficient. Positive inotropic and vasodilating agents should be avoided. In severe cases with refractory cardiogenic shock, early treatment with mechanical support using venoarterial extracorporeal membrane oxygenation or a LV assist device should be considered.
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Affiliation(s)
- Elmir Omerovic
- Department of Molecular and Clinical Medicine, Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Bruna stråket 16, Gothenburg, Sweden; Department of Cardiology, Sahlgrenska University Hospital, Bruna stråket 16, Gothenburg 413 45, Sweden.
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63
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Nieminen MS, Fonseca C, Brito D, Wikström G. The potential of the inodilator levosimendan in maintaining quality of life in advanced heart failure. Eur Heart J Suppl 2017; 19:C15-C21. [PMID: 29249906 PMCID: PMC5932556 DOI: 10.1093/eurheartj/sux003] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
Maintaining adequate quality of life (QoL) is an important therapeutic objective for patients with advanced heart failure and, for some patients, may take precedence over prolonging life. Achieving good QoL in this context may involve aspects of patient care that lie outside the familiar limits of heart failure treatment. The inodilator levosimendan may be advantageous in this setting, not least because of its sustained duration of action, ascribed to a long-acting metabolite designated OR-1896. The possibility of using this drug in an outpatient setting is a notable practical advantage that avoids the need for patients to attend a clinic appointment. Intermittent therapy can be integrated into a wider system of outreach and patient monitoring. Practical considerations in the use of levosimendan as part of a palliative or end-of-life regimen focused on preserving QoL include the importance of starting therapy at low doses and avoiding bolus administration unless immediate effects are required and patients have adequate baseline arterial blood pressure.
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Affiliation(s)
- Markku S Nieminen
- Heart and Lung Center, Helsinki University Hospital, Meilahti Tower Hospital, PL 340, 00029 HUS Helsinki, Finland
| | - Cândida Fonseca
- Heart Failure Unit, Department of Internal Medicine, Hospital Sao Francisco Xavier, Centro Hospitalar Lisboa Ocidental, Estrada do Forte do Alto do Duque, 1449-005 Lisboa, Portugal
| | - Dulce Brito
- Department of Cardiology, Hospital de Santa Maria, Centro Hospitalar Lisboa Norte, Av. Prof. Egas Moniz, 1649-035 Lisboa, Portugal
| | - Gerhard Wikström
- Department of Cardiology, Institute of Medical Sciences, Uppsala University, Akademiska sjukhuset, Ing.40, 5 tr, 751 85 Uppsala, Sweden
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Left Ventricular Assist Devices or Inotropes for Decreasing Pulmonary Vascular Resistance in Patients with Pulmonary Hypertension Listed for Heart Transplantation. J Card Fail 2017; 23:209-215. [DOI: 10.1016/j.cardfail.2016.06.421] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2016] [Revised: 06/16/2016] [Accepted: 06/28/2016] [Indexed: 11/22/2022]
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65
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Cuthbert JJ, Pellicori P, Shah P, Clark AL. New pharmacological approaches in heart failure therapy: developments and possibilities. Future Cardiol 2017; 13:173-188. [PMID: 28181443 DOI: 10.2217/fca-2016-0068] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023] Open
Abstract
There have been few major breakthroughs in heart failure (HF) drug therapies in recent years yet HF morbidity and mortality remain high, and there is a clear need for further research. Several newer agents that appear promising in Phase I and II trials do not progress to show clinical benefit in later trials. Part of the failure to find new therapies may lie in flawed trial design compounded by the need for ever-increasing patient numbers in order to prove outcome benefit. We summarize some of the most recent and promising medical therapies for HF.
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Affiliation(s)
- Joseph J Cuthbert
- Department of Cardiology, Hull York Medical School, Hull & East Yorkshire Medical Research & Teaching Centre, Castle Hill Hospital, Cottingham, Kingston upon Hull HU16 5JQ, UK
| | - Pierpaolo Pellicori
- Department of Cardiology, Hull York Medical School, Hull & East Yorkshire Medical Research & Teaching Centre, Castle Hill Hospital, Cottingham, Kingston upon Hull HU16 5JQ, UK
| | - Parin Shah
- Department of Cardiology, Hull York Medical School, Hull & East Yorkshire Medical Research & Teaching Centre, Castle Hill Hospital, Cottingham, Kingston upon Hull HU16 5JQ, UK
| | - Andrew L Clark
- Department of Cardiology, Hull York Medical School, Hull & East Yorkshire Medical Research & Teaching Centre, Castle Hill Hospital, Cottingham, Kingston upon Hull HU16 5JQ, UK
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Choc cardiogénique sévère : quel régime thérapeutique médicamenteux optimal ? Intérêt de l’association vasopresseurs–inotropes avec effet vasodilatateur. MEDECINE INTENSIVE REANIMATION 2017. [DOI: 10.1007/s13546-017-1260-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
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67
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Psotka MA, Teerlink JR. Direct Myosin Activation by Omecamtiv Mecarbil for Heart Failure with Reduced Ejection Fraction. Handb Exp Pharmacol 2017; 243:465-490. [PMID: 28315072 DOI: 10.1007/164_2017_13] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/06/2023]
Abstract
Myosin is the indispensable molecular motor that utilizes chemical energy to produce force for contraction within the cardiac myocyte. Myosin activity is gated by intracellular calcium levels which are regulated by multiple upstream signaling cascades that can be altered for clinical utility using inotropic medications. In contrast to clinically available cardiac inotropes, omecamtiv mecarbil is a novel direct myosin activator developed to augment left ventricular systolic function without the undesirable secondary effects of altered calcium homeostasis. Its identification and synthesis followed high-throughput screening of a reconstituted sarcomere, deliberate optimization, exquisite biochemical evaluation, and subsequently promising effects in animal models were demonstrated. Physiologically, it prolonged the duration of left ventricular systole in animal models, healthy adults, and patients with heart failure with reduced ejection fraction (HFrEF) without changing the velocity of pressure development, as assessed in animal models. It has been formulated for both intravenous and oral administration, and in both acute and chronic settings produced similar alterations in the duration of systole associated with beneficial increases in cardiac output, improvements in left ventricular volumes, and reductions in heart rate and often of natriuretic peptides. Small, asymptomatic increases in troponin were also observed in the absence of clinically evident ischemia. Clinically, the question remains as to whether the possible harm of this minimal troponin release is outweighed by the potential benefits of reduced neurohormonal activation, increased stroke volume and cardiac output, and improved ventricular remodeling in patients treated with omecamtiv mecarbil. The resolution of this question is being addressed by a phase III outcomes trial of this potential novel therapy for heart failure.
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Affiliation(s)
- Mitchell A Psotka
- School of Medicine, University of California San Francisco, San Francisco, CA, USA
| | - John R Teerlink
- School of Medicine, University of California San Francisco, San Francisco, CA, USA.
- Section of Cardiology, 111C, San Francisco Veterans Affairs Medical Center, 4150 Clement St, San Francisco, CA, 94121-1545, USA.
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Amado J, Gago P, Santos W, Mimoso J, de Jesus I. Choque cardiogénico – fármacos inotrópicos e vasopressores. Rev Port Cardiol 2016; 35:681-695. [DOI: 10.1016/j.repc.2016.08.004] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2015] [Revised: 06/28/2016] [Accepted: 08/26/2016] [Indexed: 01/25/2023] Open
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Amado J, Gago P, Santos W, Mimoso J, de Jesus I. Cardiogenic shock: Inotropes and vasopressors. REVISTA PORTUGUESA DE CARDIOLOGIA (ENGLISH EDITION) 2016. [DOI: 10.1016/j.repce.2016.08.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
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Karatolios K, Chatzis G, Markus B, Luesebrink U, Richter A, Schieffer B. Biventricular unloading in patients with refractory cardiogenic shock. Int J Cardiol 2016; 222:247-252. [DOI: 10.1016/j.ijcard.2016.07.227] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/15/2016] [Accepted: 07/29/2016] [Indexed: 10/21/2022]
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Fruhwald S, Pollesello P, Fruhwald F. Advanced heart failure: an appraisal of the potential of levosimendan in this end-stage scenario and some related ethical considerations. Expert Rev Cardiovasc Ther 2016; 14:1335-1347. [PMID: 27778514 DOI: 10.1080/14779072.2016.1247694] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
INTRODUCTION The later stages of heart failure are characterized by a steady decline in quality of life. Clinical priorities should be to maintain functional capacity and quality of life. In the absence of sufficient organs for transplantation, options include left ventricular assist devices and inotropic support. Areas covered: We examined data published in the last two decades on the use of inotropes and inodilators in advanced heart failure. Expert commentary: In the literature, use of conventional inotropes, including adrenergic agonists and phosphodiesterase inhibitors, appears to be suboptimal for achieving the clinical priorities of late-stage heart failure. Evidence suggests instead that the calcium-sensitizing inodilator levosimendan, administered intermittently, delivers improvements in functional capacity and quality of life and does so with no adverse impact on life expectancy. At a terminal or near-terminal stage of heart failure, the therapeutic philosophy should shift towards meeting patients' existential priorities rather than traditional heart failure-centric targets.
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Affiliation(s)
- Sonja Fruhwald
- a Department of Anesthesiology and Intensive Care Medicine, Division of Anesthesiology for Cardiovascular Surgery and Intensive Care Medicine , Medical University of Graz , Graz , Austria
| | - Piero Pollesello
- b Critical Care Proprietary Products , Orion Pharma , Espoo , Finland
| | - Friedrich Fruhwald
- c Department of Internal Medicine, Division of Cardiology , Medical University of Graz , Graz , Austria
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Kivikko M, Pollesello P, Tarvasmäki T, Sarapohja T, Nieminen MS, Harjola VP. Effect of baseline characteristics on mortality in the SURVIVE trial on the effect of levosimendan vs dobutamine in acute heart failure: Sub-analysis of the Finnish patients. Int J Cardiol 2016; 215:26-31. [PMID: 27107540 DOI: 10.1016/j.ijcard.2016.04.064] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/15/2016] [Accepted: 04/11/2016] [Indexed: 01/16/2023]
Abstract
BACKGROUND In the SURVIVE trial, including 1327 acute heart failure patients, no statistically significant difference between levosimendan and dobutamine in the 180-day all-cause mortality was seen. Country-specific differences in outcome were, however, present. In the Finnish sub-population in fact, mortality was significantly lower in levosimendan treated patients. We aim to understand the reasons for this disparity. METHODS The risk factors for all-cause mortality were identified in the whole study population using multivariate Cox proportional hazards regression analysis. Those factors were evaluated in the 95 patients of the Finnish sub-population. RESULTS The treatment by country interaction for mortality in Finland vs. other countries was significant, p=0.029. Levosimendan treated patients had a lower 180-day mortality compared to dobutamine treated (17% vs. 40%, p=0.023) in the Finnish sub-population. Baseline variables predicting survival in the whole SURVIVE trial population included age, systolic blood pressure, heart rate, myocardial infarction during admission, levels of NT-pro-BNP, glucose, creatinine, and alanine transferase, use of ACE inhibitors and β-blockers, oliguria, time from hospital admission to randomization, history of cardiac arrest, and left ventricular ejection fraction. Finnish patients were more frequently treated with β-blockers (88% vs. 52%, p<0.0001), their study treatment was started earlier (mean±SD 41±40h vs. 81±154; p<0.0001), and they had more often acute myocardial infarction at admission (39% vs. 16%, p<0.0001). CONCLUSION The lower mortality in the Finnish patients treated with levosimendan was associated with higher use of β-blockers, higher frequency of myocardial infarction at admission, and shorter delay between randomization and start of treatment.
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Pollesello P, Parissis J, Kivikko M, Harjola VP. Levosimendan meta-analyses: Is there a pattern in the effect on mortality? Int J Cardiol 2016; 209:77-83. [DOI: 10.1016/j.ijcard.2016.02.014] [Citation(s) in RCA: 66] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/09/2015] [Revised: 01/18/2016] [Accepted: 02/01/2016] [Indexed: 01/12/2023]
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Long-term intravenous inotropes in low-output terminal heart failure? Clin Res Cardiol 2016; 105:471-81. [DOI: 10.1007/s00392-016-0968-y] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/14/2015] [Accepted: 02/01/2016] [Indexed: 10/22/2022]
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75
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Silvetti S, Nieminen MS. Repeated or intermittent levosimendan treatment in advanced heart failure: An updated meta-analysis. Int J Cardiol 2016; 202:138-43. [DOI: 10.1016/j.ijcard.2015.08.188] [Citation(s) in RCA: 47] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/11/2015] [Accepted: 08/21/2015] [Indexed: 11/29/2022]
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76
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Calcium sensitizers: What have we learned over the last 25years? Int J Cardiol 2016; 203:543-8. [DOI: 10.1016/j.ijcard.2015.10.240] [Citation(s) in RCA: 47] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/26/2015] [Revised: 10/30/2015] [Accepted: 10/31/2015] [Indexed: 01/10/2023]
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77
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Wang XC, Zhu DM, Shan YX. Dobutamine Therapy is Associated with Worse Clinical Outcomes Compared with Nesiritide Therapy for Acute Decompensated Heart Failure: A Systematic Review and Meta-Analysis. Am J Cardiovasc Drugs 2015; 15:429-37. [PMID: 26123415 DOI: 10.1007/s40256-015-0134-3] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
Abstract
BACKGROUND Inotropes and natriuretic peptides are essential components of current therapeutic options for acute decompensated heart failure (ADHF). This systematic review examines the therapeutic effectiveness of dobutamine and brain natriuretic peptide, nesiritide, in reducing mortality and readmission rates for ADHF treatment. METHODS Published studies related to dobutamine and nesiritide therapy in ADHF were identified via an exhaustive search of scientific literature databases. The identified studies, published between 2002 and 2012, were carefully screened based on our predefined inclusion criteria. Selected studies were pooled, and odds ratios (ORs) and 95% confidence intervals (95% CI) for each outcome were calculated. Subgroup analysis was conducted to assess the influence of ethnicity on the study outcome. RESULTS Seven cohort studies were selected for this meta-analysis. These seven studies included 959 ADHF patients who underwent nesiritide treatment and 1748 ADHF patients who received dobutamine therapy. Our meta-analysis revealed a significantly lower survival rate in dobutamine-treated patients compared with nesiritide-treated patients (OR 0.48, 95% CI 0.36-0.63, P < 0.001). Additionally, a markedly higher readmission rate was associated with dobutamine treatment compared with nesiritide treatment (OR 0.52, 95% CI 0.36-0.73, P < 0.001). A stratified analysis based on ethnicity revealed a significantly lower survival in dobutamine-treated ADHF patients in Caucasian and mixed populations compared with nesiritide treatment (Caucasian: OR 0.60, 95% CI 0.38-0.94, P = 0.024; Mixed: OR 0.38, 95% CI 0.26-0.56, P < 0.001). However, a similar association was not detected in Asian populations (P = 0.738). Further, dobutamine-treated ADHF patients displayed higher readmission rates than did nesiritide-treated patients in both Caucasian and mixed-race populations (all P < 0.05). CONCLUSIONS Our study suggests that dobutamine therapy is associated with poorer outcomes, with higher in-hospital mortality rates and increased readmission rates compared with nesiritide therapy in ADHF patients. Thus, current treatment strategies need to be redesigned for better outcomes.
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Affiliation(s)
- Xiao-Chen Wang
- Department of Thoracic and Cardiac Surgery, The First Affiliated Hospital of Soochow University, Suzhou, People's Republic of China
- Department of Thoracic and Cardiac Surgery, The Affiliated Jiangyin Hospital of Southest University Medical College, Jiangyin, People's Republic of China
| | - Dong-Min Zhu
- Department of Cardiology, Nursing College of Nanjing Medical University, Nanjing, People's Republic of China
- Department of Cardiology, The Affiliated Jiangyin Hospital of Southest University Medical College, Jiangyin, Jiangyin, People's Republic of China
| | - Yu-Xuan Shan
- Department of Cardiology, Linfen People's Hospital, No. 17, Liberation Road, Linfen, 041000, People's Republic of China.
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Lv MY, Deng SL, Long XF. Retraction. rhBNP therapy can improve clinical outcomes and reduce in-hospital mortality compared with dobutamine in heart failure patients: a meta-analysis. Br J Clin Pharmacol 2015; 81:174-85. [PMID: 26382927 DOI: 10.1111/bcp.12788] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2015] [Revised: 09/11/2015] [Accepted: 09/15/2015] [Indexed: 12/27/2022] Open
Abstract
AIMS A meta-analysis was performed to compare the therapeutic outcomes in patients treated for heart failure (HF) with recombinant human brain natriuretic peptide (rhBNP) and dobutamine. METHODS PubMed, Embase and the Chinese Biomedical Database were exhaustively searched to identify studies relevant to this meta-analysis. Eight cohort studies were found suitable for inclusion. Data regarding trial validity, methodological processes and clinical outcomes were extracted. RESULTS Patients treated with rhBNP showed statistically significant reduction of in-hospital mortality and re-admission rates compared with the dobutamine treated patient group (both P < 0.05). Further, the rhBNP treated patient group showed higher survival outcomes, compared with dobutamine treated patients, when the post-treatment follow-up period was longer than 6 months (P < 0.05). Stratified analysis based on ethnicity showed a dramatic decrease of in-hospital mortality among mixed race HF patients receiving rhBNP treatment (P < 0.05), but such decreases were not statistically significant in Asian and Caucasian populations (both P > 0.05). On the other hand, re-admission rates were significantly lower in rhBNP treated Caucasian and mixed race populations (both P < 0.05). Notably, in rhBNP treated group, dose levels of 0.015 and 0.03 incrementally lowered the re-admission rates, displaying dose effect, and the re-admission rates at both rhBNP doses were significantly lower than the dobutamine treated group (both P < 0.05). CONCLUSIONS Our meta-analysis results suggested that rhBNP therapy is associated with lower in-hospital mortality and re-admission rates in HF patients compared to the dobutamine regimen. Nevertheless, large scale prospective, randomized trials are necessary to confirm these findings.
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Affiliation(s)
- Ming-Yi Lv
- Department of Internal Medicine, ICU, Affiliated Zhongshan Hospital of Dalian University, Dalian, 116000, Liaoning Province, P.R. China
| | - Shu-Ling Deng
- Department of Internal Medicine, ICU, Affiliated Zhongshan Hospital of Dalian University, Dalian, 116000, Liaoning Province, P.R. China
| | - Xiao-Feng Long
- Department of Internal Medicine, ICU, Affiliated Zhongshan Hospital of Dalian University, Dalian, 116000, Liaoning Province, P.R. China
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Paternoster G, Guarracino F. Sepsis After Cardiac Surgery: From Pathophysiology to Management. J Cardiothorac Vasc Anesth 2015; 30:773-80. [PMID: 26947713 DOI: 10.1053/j.jvca.2015.11.009] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/19/2015] [Indexed: 11/11/2022]
Affiliation(s)
- Gianluca Paternoster
- U.O.C. Cardiac Anaesthesia and Cardiac-Intensive Care, San Carlo Hospital, Potenza, Italy.
| | - Fabio Guarracino
- Department of Anaesthesia and Critical Care Medicine, Azienda Ospedaliero Universitaria Pisana, Pisa, Italy
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80
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Schmid E, Neef S, Berlin C, Tomasovic A, Kahlert K, Nordbeck P, Deiss K, Denzinger S, Herrmann S, Wettwer E, Weidendorfer M, Becker D, Schäfer F, Wagner N, Ergün S, Schmitt JP, Katus HA, Weidemann F, Ravens U, Maack C, Hein L, Ertl G, Müller OJ, Maier LS, Lohse MJ, Lorenz K. Cardiac RKIP induces a beneficial β-adrenoceptor-dependent positive inotropy. Nat Med 2015; 21:1298-306. [PMID: 26479924 DOI: 10.1038/nm.3972] [Citation(s) in RCA: 48] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2015] [Accepted: 09/12/2015] [Indexed: 01/08/2023]
Abstract
In heart failure therapy, it is generally assumed that attempts to produce a long-term increase in cardiac contractile force are almost always accompanied by structural and functional damage. Here we show that modest overexpression of the Raf kinase inhibitor protein (RKIP), encoded by Pebp1 in mice, produces a well-tolerated, persistent increase in cardiac contractility that is mediated by the β1-adrenoceptor (β1AR). This result is unexpected, as β1AR activation, a major driver of cardiac contractility, usually has long-term adverse effects. RKIP overexpression achieves this tolerance via simultaneous activation of the β2AR subtype. Analogously, RKIP deficiency exaggerates pressure overload-induced cardiac failure. We find that RKIP expression is upregulated in mouse and human heart failure, indicative of an adaptive role for RKIP. Pebp1 gene transfer in a mouse model of heart failure has beneficial effects, suggesting a new therapeutic strategy for heart failure therapy.
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Affiliation(s)
- Evelyn Schmid
- Department of Pharmacology, Institute of Pharmacology and Toxicology, Würzburg, Germany
| | - Stefan Neef
- Department of Internal Medicine II, University Hospital Regensburg, Regensburg, Germany
| | - Christopher Berlin
- Department of Pharmacology, Institute of Pharmacology and Toxicology, Würzburg, Germany
| | - Angela Tomasovic
- Department of Pharmacology, Institute of Pharmacology and Toxicology, Würzburg, Germany
| | - Katrin Kahlert
- Department of Pharmacology, Institute of Pharmacology and Toxicology, Würzburg, Germany
| | - Peter Nordbeck
- Comprehensive Heart Failure Center, Würzburg, Germany.,Department of Internal Medicine I, University of Würzburg, Würzburg, Germany
| | - Katharina Deiss
- Department of Pharmacology, Institute of Pharmacology and Toxicology, Würzburg, Germany
| | - Sabrina Denzinger
- Department of Pharmacology, Institute of Pharmacology and Toxicology, Würzburg, Germany
| | - Sebastian Herrmann
- Comprehensive Heart Failure Center, Würzburg, Germany.,Department of Internal Medicine I, University of Würzburg, Würzburg, Germany
| | - Erich Wettwer
- Department of Pharmacology and Toxicology, Medical Faculty Gustav Carus, Dresden University of Technology, Dresden, Germany
| | - Markus Weidendorfer
- Department of Pharmacology, Institute of Pharmacology and Toxicology, Würzburg, Germany
| | - Daniel Becker
- Department of Pharmacology, Institute of Pharmacology and Toxicology, Würzburg, Germany
| | - Florian Schäfer
- Department of Pharmacology, Institute of Pharmacology and Toxicology, Würzburg, Germany
| | - Nicole Wagner
- Institute of Anatomy and Cell Biology, Würzburg, Germany
| | - Süleyman Ergün
- Institute of Anatomy and Cell Biology, Würzburg, Germany
| | - Joachim P Schmitt
- Department of Pharmacology, Institute of Pharmacology and Toxicology, Würzburg, Germany
| | - Hugo A Katus
- Department of Internal Medicine III, Heidelberg University Hospital, Heidelberg, Germany.,German Centre for Cardiovascular Research, Heidelberg University Hospital, Heidelberg, Germany
| | - Frank Weidemann
- Comprehensive Heart Failure Center, Würzburg, Germany.,Department of Internal Medicine I, University of Würzburg, Würzburg, Germany
| | - Ursula Ravens
- Department of Pharmacology and Toxicology, Medical Faculty Gustav Carus, Dresden University of Technology, Dresden, Germany
| | - Christoph Maack
- Clinic for Internal Medicine III, Saarland University Hospital, Homburg, Germany
| | - Lutz Hein
- Institute of Experimental and Clinical Pharmacology and Toxicology, Freiburg, Germany.,Centre for Biological Signalling Studies (BIOSS), University of Freiburg, Freiburg, Germany
| | - Georg Ertl
- Comprehensive Heart Failure Center, Würzburg, Germany.,Department of Internal Medicine I, University of Würzburg, Würzburg, Germany
| | - Oliver J Müller
- Department of Internal Medicine III, Heidelberg University Hospital, Heidelberg, Germany.,German Centre for Cardiovascular Research, Heidelberg University Hospital, Heidelberg, Germany
| | - Lars S Maier
- Department of Internal Medicine II, University Hospital Regensburg, Regensburg, Germany
| | - Martin J Lohse
- Department of Pharmacology, Institute of Pharmacology and Toxicology, Würzburg, Germany.,Comprehensive Heart Failure Center, Würzburg, Germany
| | - Kristina Lorenz
- Department of Pharmacology, Institute of Pharmacology and Toxicology, Würzburg, Germany.,Comprehensive Heart Failure Center, Würzburg, Germany
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81
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Gaudard P, Mourad M, Eliet J, Zeroual N, Culas G, Rouvière P, Albat B, Colson P. Management and outcome of patients supported with Impella 5.0 for refractory cardiogenic shock. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2015; 19:363. [PMID: 26453047 PMCID: PMC4600310 DOI: 10.1186/s13054-015-1073-8] [Citation(s) in RCA: 81] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/08/2015] [Accepted: 09/20/2015] [Indexed: 12/20/2022]
Abstract
Introduction Cardiogenic shock refractory to standard therapy with inotropes and/or intra-aortic balloon pump is accompanied with an unacceptable high mortality. Percutaneous left ventricular assist devices may provide a survival benefit for these very sick patients. In this study, we describe our experience with the Impella 5.0 device used in the setting of refractory cardiogenic shock. Methods In this observational, retrospective, single-center study we included all the consecutive patients supported with Impella 5.0, between May 2008 and December 2013, for refractory cardiogenic shock. Patients’ baseline and procedural characteristics, hemodynamics and outcome to the first 48 h of support, to ICU discharge and day-28 visit were collected. Results A total of 40 patients were included in the study. Median age was 57 years and 87.5 % were male. Cardiogenic shock resulted from acute myocardial infarction in 17 patients (43 %), dilated cardiomyopathy in 12 (30 %) and postcardiotomy cardiac failure in 7 (18 %). In 15 patients Impella 5.0 was added to an ECMO to unload the left ventricle. The median SOFA score for the entire cohort prior to circulatory support was 12 [10–14] and the duration of Impella support was 7 [5–10] days. We observed a significant decrease of the inotrope score (10 [1–17] vs. 1 [0–9]; p = 0.04) and the lactate values (3.8 [1.7–5.9] mmol/L vs. 2.5 [1.5–3.4] mmol/L; p = 0.01) after 6 h of support with Impella 5.0. Furthermore, at Impella removal the patients’ left ventricular ejection fraction improved significantly (p < 0.001) when compared to baseline. Cardiac recovery, bridge to left ventricular assist device or heart transplantation was possible in 28 patients (70 %). Twenty-six patients (65 %) survived at day 28. A multivariate analysis showed a higher risk of mortality for patients with acute myocardial infarction (hazard ratio = 4.1 (1.2–14.2); p = 0.02). Conclusions Impella 5.0 allowed fast weaning of inotropes and might facilitate myocardial recovery. Despite high severity scores at admission, day-28 mortality rate was better than predicated.
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Affiliation(s)
- Philippe Gaudard
- Department of Anesthesiology and Critical Care Medicine, Arnaud de Villeneuve Hospital, CHRU Montpellier, 371 Avenue du Doyen Gaston Giraud, 34295, Montpellier, France. .,PhyMedExp, University of Montpellier, INSERM U1046, CNRS UMR9214, 371 avenue du Doyen G. Giraud, 34295, Montpellier, France.
| | - Marc Mourad
- Department of Anesthesiology and Critical Care Medicine, Arnaud de Villeneuve Hospital, CHRU Montpellier, 371 Avenue du Doyen Gaston Giraud, 34295, Montpellier, France.
| | - Jacob Eliet
- Department of Anesthesiology and Critical Care Medicine, Arnaud de Villeneuve Hospital, CHRU Montpellier, 371 Avenue du Doyen Gaston Giraud, 34295, Montpellier, France.
| | - Norddine Zeroual
- Department of Anesthesiology and Critical Care Medicine, Arnaud de Villeneuve Hospital, CHRU Montpellier, 371 Avenue du Doyen Gaston Giraud, 34295, Montpellier, France.
| | - Geraldine Culas
- Department of Anesthesiology and Critical Care Medicine, Arnaud de Villeneuve Hospital, CHRU Montpellier, 371 Avenue du Doyen Gaston Giraud, 34295, Montpellier, France.
| | - Philippe Rouvière
- Department of Cardiac Surgery, Arnaud de Villeneuve Hospital, CHRU Montpellier, 371 Avenue du Doyen Gaston Giraud, 34295, Montpellier, France.
| | - Bernard Albat
- Department of Cardiac Surgery, Arnaud de Villeneuve Hospital, CHRU Montpellier, 371 Avenue du Doyen Gaston Giraud, 34295, Montpellier, France.
| | - Pascal Colson
- Department of Anesthesiology and Critical Care Medicine, Arnaud de Villeneuve Hospital, CHRU Montpellier, 371 Avenue du Doyen Gaston Giraud, 34295, Montpellier, France.
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Mushtaq S, Andreini D, Farina S, Salvioni E, Pontone G, Sciomer S, Volpato V, Agostoni P. Levosimendan improves exercise performance in patients with advanced chronic heart failure. ESC Heart Fail 2015; 2:133-141. [PMID: 27708855 PMCID: PMC5042087 DOI: 10.1002/ehf2.12047] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2015] [Revised: 05/15/2015] [Accepted: 06/02/2015] [Indexed: 11/06/2022] Open
Abstract
AIMS Cardiopulmonary exercise test (CPET) provides parameters such as peak VO2 and ventilation/CO2 production (VE/VCO2) slope, which are strong prognostic predictors in patients with stable advanced chronic heart failure (ADHF). The study aim was to evaluate the effects of the inodilator levosimendan on CPET in patients with ADHF under stable clinical conditions. METHODS AND RESULTS We enrolled patients with ADHF (peak VO2 < 12 mL/min/kg) in a double-blind, placebo-controlled protocol. Patients were randomly assigned to i.v. infusion of placebo (500 mL 5% glucose; n = 19) or levosimendan (in 500 mL 5% glucose; n = 23). Before and 24 h after the end of the infusion, patients underwent determination of New York Heart Association class, B-type natriuretic peptide (BNP), haemoglobin, serum creatinine, and blood urea nitrogen levels, as well as CPET, standard spirometry, and alveolar capillary gas diffusion. BNP showed no change with placebo (1042 ± 811 to 1043 ± 867 pg/mL), but it was decreased with levosimendan (1163 ± 897 to 509 ± 543 pg/mL, P < 0.001). No changes were observed for haemoglobin, creatinine, and blood urea nitrogen in either group. With levosimendan, a minor improvement was observed in spirometry measurements, but not in alveolar capillary gas diffusion. Peak VO2 showed a small, non-significant increase with placebo (9.5 ± 1.7 to 10.0 ± 2.1 mL/kg/min, P = 0.12), and a greater increase with levosimendan (9.8 ± 1.7 to 11.0 ± 1.9 mL/kg/min, P < 0.005). The VE/VCO2 slope showed no change (44.0 ± 11 vs. 43.4 ± 10.3, P = 0.44), and a decrease (41.9 ± 10 vs. 36.6 ± 6.4, P < 0.001) in the placebo and in the levosimendan group, respectively. CONCLUSION Levosimendan treatment significantly improves peak VO2 and reduces VE/VCO2 slope and BNP in patients with ADHF.
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Affiliation(s)
- Saima Mushtaq
- Centro Cardiologico MonzinoScientific Institute for Research, Hospitalisation and Health Care (IRCCS)MilanItaly
| | - Daniele Andreini
- Centro Cardiologico MonzinoScientific Institute for Research, Hospitalisation and Health Care (IRCCS)MilanItaly
- Cardiovascular Section, Department of Clinical Sciences and Community HealthUniversity of MilanMilanItaly
| | - Stefania Farina
- Centro Cardiologico MonzinoScientific Institute for Research, Hospitalisation and Health Care (IRCCS)MilanItaly
| | - Elisabetta Salvioni
- Centro Cardiologico MonzinoScientific Institute for Research, Hospitalisation and Health Care (IRCCS)MilanItaly
| | - Gianluca Pontone
- Centro Cardiologico MonzinoScientific Institute for Research, Hospitalisation and Health Care (IRCCS)MilanItaly
| | - Susanna Sciomer
- Department of Cardiovascular, Respiratory, Nephrological, Anaesthesiological and Geriatric Sciences‘La Sapienza’ University of RomeRomeItaly
| | - Valentina Volpato
- Centro Cardiologico MonzinoScientific Institute for Research, Hospitalisation and Health Care (IRCCS)MilanItaly
| | - Piergiuseppe Agostoni
- Centro Cardiologico MonzinoScientific Institute for Research, Hospitalisation and Health Care (IRCCS)MilanItaly
- Cardiovascular Section, Department of Clinical Sciences and Community HealthUniversity of MilanMilanItaly
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83
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Value of Low-Dose Dobutamine Stress Real-Time Myocardial Contrast Echocardiography in the Diagnosis of Coronary Heart Disease. Am J Ther 2015; 24:e270-e277. [PMID: 26164027 DOI: 10.1097/mjt.0000000000000273] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
To investigate the value of low-dose dobutamine stress real-time myocardial contrast echocardiography (RT-MCE) in the diagnosis of coronary heart disease (CHD). A total of 65 hospitalized patients with suspected or confirmed CHD were detected by RT-MCE combined with low-dose dobutamine stress (0.84 mg/kg). Perfusion curves were quantitatively analyzed using QLAB software. Peak intensity (A), slope of curves (β), and perfusion (A × β) were also calculated. Based on the results of coronary angiography, patients were divided into no obvious stenosis group (<50%), mild stenosis group (50%-74%), moderate stenosis group (75%-89%), and severe stenosis group (≥90%). The A, β, and A × β values before and after low-dose dobutamine stress of each group were compared. In the basal state and after low-dose dobutamine stress, the A, β, and A × β values significantly decreased as the stenosis degree of the myocardial segments increased. The same variation tendency was also found in the A, β, and A × β reserve values, and there was significant difference in these reserve values between moderate and severe stenosis groups and no obvious stenosis and mild stenosis groups. Collateral circulation had marked effects on the values of myocardial perfusion parameters and their reserve values, especially in the segments with severe stenosis. Low-dose dobutamine stress RT-MCE can be a sensitive method for clinical diagnosis and risk assessment of CHD and may provide a basis for further treatment of CHD.
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84
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Liaudet L, Calderari B, Pacher P. Pathophysiological mechanisms of catecholamine and cocaine-mediated cardiotoxicity. Heart Fail Rev 2015; 19:815-24. [PMID: 24398587 DOI: 10.1007/s10741-014-9418-y] [Citation(s) in RCA: 90] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
Overactivation of the sympatho-adrenergic system is an essential mechanism providing short-term adaptation to the stressful conditions of critical illnesses. In the same way, the administration of exogenous catecholamines is mandatory to support the failing circulation in acutely ill patients. In contrast to these short-term benefits, prolonged adrenergic stress is detrimental to the cardiovascular system by initiating a series of adverse effects triggering significant cardiotoxicity, whose pathophysiological mechanisms are complex and only partially elucidated. In addition to the development of myocardial oxygen supply/demand imbalance induced by the sustained activation of adrenergic receptors, catecholamines can damage cardiomyocytes by fostering mitochondrial dysfunction, via two main mechanisms. The first one is calcium overload, consecutive to β-adrenergic receptor-mediated activation of protein kinase A and subsequent phosphorylation of multiple Ca(2+)-cycling proteins. The second one is oxidative stress, primarily related to the transformation of catecholamines into "aminochromes," which undergo redox cycling in mitochondria to generate copious amounts of oxygen-derived free radicals. In turn, calcium overload and oxidative stress promote mitochondrial permeability transition and cardiomyocyte cell death, both via the apoptotic and necrotic pathways. Comparable mechanisms of myocardial toxicity, including marked oxidative stress and mitochondrial dysfunction, have been reported with the use of cocaine, a common recreational drug with potent sympathomimetic activity. The aim of the current review is to present in detail the pathophysiological processes underlying the development of catecholamine and cocaine-induced cardiomyopathy, as such conditions may be frequently encountered in the clinical practice of cardiologists and ICU specialists.
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Affiliation(s)
- Lucas Liaudet
- Department of Intensive Care Medicine and Burn Center, Faculty of Biology and Medicine, University Hospital Medical Center, BH 08-621, 1010, Lausanne, Switzerland,
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85
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Understanding the differences among inotropes. Intensive Care Med 2015; 41:1388. [DOI: 10.1007/s00134-015-3896-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/21/2015] [Indexed: 10/23/2022]
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86
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Katz JN, Waters SB, Hollis IB, Chang PP. Advanced therapies for end-stage heart failure. Curr Cardiol Rev 2015; 11:63-72. [PMID: 24251460 PMCID: PMC4347211 DOI: 10.2174/1573403x09666131117163825] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/09/2013] [Revised: 06/09/2013] [Accepted: 09/27/2013] [Indexed: 11/22/2022] Open
Abstract
Management of the advanced heart failure patient can be complex. Therapies include cardiac transplantation and mechanical circulatory support, as well inotropic agents for the short-term. Despite a growing armamentarium of resources, the clinician must carefully weigh the risks and benefits of each therapy to develop an optimal treatment strategy. While cardiac transplantation remains the only true “cure” for end-stage disease, this resource is limited and the demand continues to far outpace the supply. For patients who are transplant-ineligible or likely to succumb to their illness prior to transplant, ventricular assist device therapy has now become a viable option for improving morbidity and mortality. Particularly for the non-operative pa-tient, intravenous inotropes can be utilized for symptom control. Regardless of the treatments considered, care of the heart failure patient requires thoughtful dialogue, multidisciplinary collaboration, and individualized care. While survival is important, most patients covet quality of life above all outcomes. An often overlooked component is the patient’s control over the dying process. It is vital that clinicians make goals-of-care discussions a priority when seeing patients with advanced heart failure. The use of palliative care consultation is well-validated and facilitates these difficult conversations to ensure that all patient needs are ultimately met.
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Affiliation(s)
| | | | | | - Patricia P Chang
- Division of Pulmonary & Critical Care Medicine, 160 Dental Circle, CB#7075, Burnett-Womack Building, 6th Floor, Chapel Hill, NC 27599-7075, USA.
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87
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Nieminen MS, Dickstein K, Fonseca C, Serrano JM, Parissis J, Fedele F, Wikström G, Agostoni P, Atar S, Baholli L, Brito D, Colet JC, Édes I, Gómez Mesa JE, Gorjup V, Garza EH, González Juanatey JR, Karanovic N, Karavidas A, Katsytadze I, Kivikko M, Matskeplishvili S, Merkely B, Morandi F, Novoa A, Oliva F, Ostadal P, Pereira-Barretto A, Pollesello P, Rudiger A, Schwinger RHG, Wieser M, Yavelov I, Zymliński R. The patient perspective: Quality of life in advanced heart failure with frequent hospitalisations. Int J Cardiol 2015; 191:256-64. [PMID: 25981363 DOI: 10.1016/j.ijcard.2015.04.235] [Citation(s) in RCA: 114] [Impact Index Per Article: 12.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/01/2015] [Accepted: 04/30/2015] [Indexed: 12/27/2022]
Abstract
End of life is an unfortunate but inevitable phase of the heart failure patients' journey. It is often preceded by a stage in the progression of heart failure defined as advanced heart failure, and characterised by poor quality of life and frequent hospitalisations. In clinical practice, the efficacy of treatments for advanced heart failure is often assessed by parameters such as clinical status, haemodynamics, neurohormonal status, and echo/MRI indices. From the patients' perspective, however, quality-of-life-related parameters, such as functional capacity, exercise performance, psychological status, and frequency of re-hospitalisations, are more significant. The effects of therapies and interventions on these parameters are, however, underrepresented in clinical trials targeted to assess advanced heart failure treatment efficacy, and data are overall scarce. This is possibly due to a non-universal definition of the quality-of-life-related endpoints, and to the difficult standardisation of the data collection. These uncertainties also lead to difficulties in handling trade-off decisions between quality of life and survival by patients, families and healthcare providers. A panel of 34 experts in the field of cardiology and intensive cardiac care from 21 countries around the world convened for reviewing the existing data on quality-of-life in patients with advanced heart failure, discussing and reaching a consensus on the validity and significance of quality-of-life assessment methods. Gaps in routine care and research, which should be addressed, were identified. Finally, published data on the effects of current i.v. vasoactive therapies such as inotropes, inodilators, and vasodilators on quality-of-life in advanced heart failure patients were analysed.
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Affiliation(s)
| | | | - Cândida Fonseca
- S. Francisco Xavier Hospital, CHLO, NOVA Medical School, Faculdade de Ciências Médicas, Universidade Nova de Lisboa, Portugal
| | - Jose Magaña Serrano
- División de Educación en Salud, UMAE Hospital de Cardiología Centro Médico Nacional Siglo XXI, Instituto Mexicano del Seguro Social, Mexico
| | - John Parissis
- Second University Cardiology Clinic, Attiko Teaching Hospital, Athens, Greece
| | - Francesco Fedele
- Department of Cardiovascular, Respiratory, Nephrology and Geriatric Science, University of Rome, Italy
| | | | | | - Shaul Atar
- Department of Cardiology, Galilee Medical Center, Nahariya, Israel
| | - Loant Baholli
- Department of Intensive Care, Klinikum Dortmund, Germany
| | - Dulce Brito
- Cardiology Department, Hospital Universitario de Santa Maria, Lisbon, Portugal
| | | | - István Édes
- Department of Cardiology, University of Debrecen, Hungary
| | | | - Vojka Gorjup
- Department of Intensive Internal Medicine, University Medical Center Ljubljana, Slovenia
| | - Eduardo Herrera Garza
- Heart Failure, Heart Transplant Department, Centro Médico Zambrano Hellion, Heart Failure Clinic Unidad Médica de Alta Especialidad, Hospital de Cardiología No. 34, IMSS Monterrey Nuevo León, Mexico
| | | | - Nenad Karanovic
- Clinical Department of Anaesthesiology and Intensive Care, University Hospital of Split, Croatia
| | - Apostolos Karavidas
- Heart Failure Clinic & Echo Lab, Gennimatas General Hospital of Athens, Greece
| | - Igor Katsytadze
- Cardiology Intensive Care Unit, O. Bogomolets National Medical University, Kiev, Ukraine
| | | | | | - Béla Merkely
- Heart and Vascular Center, Semmelweis University, Budapest, Hungary
| | - Fabrizio Morandi
- Department of Cardiovascular Science, University of Insubria, Circolo Hospital and Macchi Foundation, Varese, Italy
| | | | - Fabrizio Oliva
- Department of Cardiology, Niguarda Ca'Granda Hospital, Milan, Italy
| | - Petr Ostadal
- Department of Cardiology, Cardiovascular Center, Na Homolce Hospital, Prague, Czech Republic
| | | | | | - Alain Rudiger
- Institute of Anaesthesiology, University Hospital Zurich, Switzerland
| | - Robert H G Schwinger
- Department of Internal Medicine, Kliniken Nordoberpfalz, Weiden, Germany; Teaching Hospital of the University of Regensburg, Germany
| | - Manfred Wieser
- Department of Internal Medicine 1, University Hospital Krems, Karl Landsteiner University of Health Sciences, Austria
| | - Igor Yavelov
- Scientific Research Institute of Physico-Chemical Medicine of the Federal Medico-Biological Agency of the Russian Federation, Moscow, Russia
| | - Robert Zymliński
- Department of Cardiology, Cardiology Intensive Care Unit, The 4th Military Hospital, Wroclaw, Poland
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Pavlovic G, Diaper J, Ellenberger C, Frei A, Bendjelid K, Bonhomme F, Licker M. Impact of early haemodynamic goal-directed therapy in patients undergoing emergency surgery: an open prospective, randomised trial. J Clin Monit Comput 2015; 30:87-99. [PMID: 25851818 DOI: 10.1007/s10877-015-9691-x] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2014] [Accepted: 03/31/2015] [Indexed: 02/06/2023]
Abstract
Haemodynamic goal-directed therapies (GDT) may improve outcome following elective major surgery. So far, few data exist regarding haemodynamic optimization during emergency surgery. In this randomized, controlled trial, 50 surgical patients with hypovolemic or septic conditions were enrolled and we compared two algorithms of GDTs based either on conventional parameters and pressure pulse variation (control group) or on cardiac index, global end-diastolic volume index and stroke volume variation as derived from the PiCCO monitoring system (optimized group). Postoperative outcome was estimated by a composite index including major complications and by the Sequential Organ Failure Assessment (SOFA) Score within the first 3 days after surgery (POD1, POD2 and POD3). Data from 43 patients were analyzed (control group, N = 23; optimized group, N = 20). Similar amounts of fluid were given in the two groups. Intraoperatively, dobutamine was given in 45 % optimized patients but in no control patients. Major complications occurred more frequently in the optimized group [19 (95 %) versus 10 (40 %) in the control group, P < 0.001]. Likewise, SOFA scores were higher in the optimized group on POD1 (10.2 ± 2.5 versus 6.6 ± 2.2 in the control group, P = 0.001), POD2 (8.4 ± 2.6 vs 5.0 ± 2.4 in the control group, P = 0.002) and POD 3 (5.2 ± 3.6 and 2.2 ± 1.3 in the control group, P = 0.01). There was no significant difference in hospital mortality (13 % in the control group and 25 % in the optimized group). Haemodynamic optimization based on volumetric and flow PiCCO-derived parameters was associated with a less favorable postoperative outcome compared with a conventional GDT protocol during emergency surgery.
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Affiliation(s)
- Gordana Pavlovic
- Department of Anaesthesiology, Pharmacology and Intensive Care, University Hospital Geneva, rue Gabrielle-Perret-Gentil, 1211, Geneva, Switzerland
| | - John Diaper
- Department of Anaesthesiology, Pharmacology and Intensive Care, University Hospital Geneva, rue Gabrielle-Perret-Gentil, 1211, Geneva, Switzerland
| | - Christoph Ellenberger
- Department of Anaesthesiology, Pharmacology and Intensive Care, University Hospital Geneva, rue Gabrielle-Perret-Gentil, 1211, Geneva, Switzerland
| | - Angela Frei
- Department of Anaesthesiology, Pharmacology and Intensive Care, University Hospital Geneva, rue Gabrielle-Perret-Gentil, 1211, Geneva, Switzerland
| | - Karim Bendjelid
- Department of Anaesthesiology, Pharmacology and Intensive Care, University Hospital Geneva, rue Gabrielle-Perret-Gentil, 1211, Geneva, Switzerland.,Faculty of medecine, University of Geneva, Geneva, Switzerland
| | - Fanny Bonhomme
- Department of Anaesthesiology, Pharmacology and Intensive Care, University Hospital Geneva, rue Gabrielle-Perret-Gentil, 1211, Geneva, Switzerland
| | - Marc Licker
- Department of Anaesthesiology, Pharmacology and Intensive Care, University Hospital Geneva, rue Gabrielle-Perret-Gentil, 1211, Geneva, Switzerland. .,Faculty of medecine, University of Geneva, Geneva, Switzerland.
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[Catecholamines: pro and contra]. Med Klin Intensivmed Notfmed 2015; 111:37-46. [PMID: 25804726 DOI: 10.1007/s00063-015-0011-5] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2014] [Revised: 11/28/2014] [Accepted: 12/18/2014] [Indexed: 12/18/2022]
Abstract
BACKGROUND Catecholamines with vasopressor and inotropic effects are commonly used in intensive care medicine. The aim of this review is to explain some of the physiologic actions on which a catecholamine therapy is based, but also to elucidate the risks which are associated with an uncritical and excessive use of these drugs. SIDE EFFECTS Emphasis is placed on the myocardial damage triggered by adrenergic overstimulation. There is considerable evidence that in conditions of severe heart failure, myocardial ischemia as well as cardiogenic and septic shock especially the use of catecholamines with predominant β-adrenergic effects (epinephrine, dobutamine, dopamine) can have a negative clinical impact. A simple cardiac risk marker might be a tachycardia. ADMINISTRATION Vasopressor therapy with norepinephrine, based on individually applied perfusion parameters (e.g., urine output, lactate), however, seems justified in many conditions of shock and hemodynamic instability during deep analgosedation. In terms of a cardioprotective therapy, the administration of catecholamines, however, should always be reevaluated and titrated to the minimum deemed necessary.
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90
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Schmieder RE, Mitrovic V, Hengstenberg C. Renal impairment and worsening of renal function in acute heart failure: can new therapies help? The potential role of serelaxin. Clin Res Cardiol 2015; 104:621-31. [PMID: 25787721 DOI: 10.1007/s00392-015-0839-y] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/08/2015] [Accepted: 03/04/2015] [Indexed: 12/29/2022]
Abstract
Renal dysfunction is a frequent finding in patients with acute heart failure (AHF) and an important prognostic factor for adverse outcomes. Worsening of renal function occurs in 30-50% of patients hospitalised for AHF, and is associated with increased mortality, prolonged hospital stay and increased risk of readmission. Likely mechanisms involved in the decrease in renal function include impaired haemodynamics and activation of neurohormonal factors, such as the renin-angiotensin-aldosterone system, the sympathetic nervous system and the arginine-vasopressin system. Additionally, many drugs currently used to treat AHF have a detrimental effect on renal function. Therefore, pharmacotherapy for AHF should carefully take into account any potential complications related to renal function. Serelaxin, currently in clinical development for the treatment of AHF is a recombinant form of human relaxin-2, identical in structure to the naturally occurring human relaxin-2 peptide hormone that mediates cardiac and renal adaptations during pregnancy. Data from both pre-clinical and clinical studies indicate a potentially beneficial effect of serelaxin on kidney function. In this review, we discuss the mechanisms and impact of impairment of renal function in AHF, and the potential benefits of new therapies, such as serelaxin, in this context.
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Affiliation(s)
- Roland E Schmieder
- Department of Nephrology and Hypertension, University Hospital of the University Erlangen-Nürnberg, Ulmenweg 18, 91054, Erlangen, Germany,
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Malfatto G, Della Rosa F, Rella V, Villani A, Branzi G, Blengino S, Giglio A, Facchini M, Parati G. Prognostic value of noninvasive hemodynamic evaluation of the acute effect of levosimendan in advanced heart failure. J Cardiovasc Med (Hagerstown) 2014; 15:322-30. [PMID: 24699010 DOI: 10.2459/01.jcm.0000435614.40439.21] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
AIMS Optimization of inotropic treatment in worsening heart failure sometimes requires invasive hemodynamic assessment in selected patients. Impedance cardiography (ICG) may be useful for a noninvasive hemodynamic evaluation. METHODS ICG was performed in 40 patients (69 ± 8 years; left ventricular ejection fraction 27.5 ± 5.6%; New York Heart Association 3.18 ± 0.34; Interagency Registry for Mechanically Assisted Circulatory Support 5.48 ± 0.96, before and after infusion of Levosimendan (0.1–0.2 µg/kg per min for up to 24 h). Echocardiogram, ICG [measuring cardiac index (CI), total peripheral resistances (TPRs) and thoracic fluid content (TFC)] and plasma levels of brain natriuretic peptide (BNP) were obtained; in nine patients, right heart catheterization was also carried out. RESULTS When right catheterization and ICG were performed simultaneously, a significant relationship was observed between values of CI and TPR, and between TFC and pulmonary wedge pressure. ICG detected the Levosimendan-induced recovery of the hemodynamic status, associated with improved systolic and diastolic function and reduction in BNP levels. One-year mortality was 4.4%. At multivariate analysis, independent predictors of mortality were: no improvement in the severity of mitral regurgitation, a persistent restrictive filling pattern (E/E’ > 15), a reduction of BNP levels below 30% and a change below 10% in CI, TPR and TFC. When combined, absence of hemodynamic improvement at ICG could predict 1-year mortality with better sensitivity (86%) and specificity (85%) than the combination of echocardiographic and BNP criteria only (sensitivity 80% and specificity 36%). CONCLUSION Noninvasive hemodynamic evaluation of heart failure patients during infusion of inodilator drugs is reliable and may help in their prognostic stratification.
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Pantos C, Mourouzis I. Translating thyroid hormone effects into clinical practice: the relevance of thyroid hormone receptor α1 in cardiac repair. Heart Fail Rev 2014; 20:273-82. [DOI: 10.1007/s10741-014-9465-4] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
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93
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Jentzer JC, Coons JC, Link CB, Schmidhofer M. Pharmacotherapy Update on the Use of Vasopressors and Inotropes in the Intensive Care Unit. J Cardiovasc Pharmacol Ther 2014; 20:249-60. [DOI: 10.1177/1074248414559838] [Citation(s) in RCA: 90] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/20/2014] [Accepted: 09/20/2014] [Indexed: 12/23/2022]
Abstract
This paper summarizes the pharmacologic properties of vasoactive medications used in the treatment of shock, including the inotropes and vasopressors. The clinical application of these therapies is discussed and recent studies describing their use and associated outcomes are also reported. Comprehension of hemodynamic principles and adrenergic and non-adrenergic receptor mechanisms are salient to the appropriate therapeutic utility of vasoactive medications for shock. Vasoactive medications can be classified based on their direct effects on vascular tone (vasoconstriction or vasodilation) and on the heart (presence or absence of positive inotropic effects). This classification highlights key similarities and differences with respect to pharmacology and hemodynamic effects. Vasopressors include pure vasoconstrictors (phenylephrine and vasopressin) and inoconstrictors (dopamine, norepinephrine, and epinephrine). Each of these medications acts as vasopressors to increase mean arterial pressure by augmenting vascular tone. Inotropes include inodilators (dobutamine and milrinone) and the aforementioned inoconstrictors. These medications act as inotropes by enhancing cardiac output through enhanced contractility. The inodilators also reduce afterload from systemic vasodilation. The relative hemodynamic effect of each agent varies depending on the dose administered, but is particularly apparent with dopamine. Recent large-scale clinical trials have evaluated vasopressors and determined that norepinephrine may be preferred as a first-line therapy for a broad range of shock states, most notably septic shock. Consequently, careful selection of vasoactive medications based on desired pharmacologic effects that are matched to the patient's underlying pathophysiology of shock may optimize hemodynamics while reducing the potential for adverse effects.
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Affiliation(s)
- Jacob C. Jentzer
- Department of Cardiology, UPMC-Presbyterian Hospital, Pittsburgh, PA, USA
- Department of Critical Care Medicine, UPMC-Presbyterian Hospital, Pittsburgh, PA
| | - James C. Coons
- Department of Cardiology, UPMC-Presbyterian Hospital, Pittsburgh, PA, USA
- University of Pittsburgh School of Pharmacy
- UPMC-Presbyterian Hospital, Pittsburgh, PA
| | | | - Mark Schmidhofer
- Heart and Vascular Institute, UPMC-Presbyterian Hospital, Pittsburgh, PA, USA
- Cardiac Intensive Care Unit
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Cardiac outcome prevention effectiveness of glucocorticoids in acute decompensated heart failure: COPE-ADHF study. J Cardiovasc Pharmacol 2014; 63:333-8. [PMID: 24710470 DOI: 10.1097/fjc.0000000000000048] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
INTRODUCTION Newly emerging evidence showed that glucocorticoids could potentiate natriuretic peptides' action by increasing the density of natriuretic peptide receptor A, leading to a potent diuresis and a renal function improvement in patients with acute decompensated heart failure (ADHF). Therefore, glucocorticoid therapy may be used in patients with ADHF. METHODS One hundred two patients with ADHF were randomized to receive glucocorticoids or standard treatment. Change from baseline in serum creatinine (SCr) at day 7 and cardiovascular death within 30 days were recorded. The study was terminated early because of slow site initiation and patient enrolment. RESULTS Glucocorticoid therapy seemed to be well tolerated. There was a remarkable SCr reduction after 7 days treatment. The change from baseline in SCr is -0.14 mg/dL in glucocorticoid group versus -0.02 mg/dL in standard treatment group (P < 0.05). Although sample size is limited, a cardiovascular death reduction at 30 days was observed in glucocorticoid group with odds ratio of 0.26 (3 deaths in glucocorticoid vs. 10 deaths in standard treatment group, P < 0.05). The survival benefit associated with glucocorticoid therapy persisted during the follow-up. Patient-assessed dyspnea and physician-assessed global clinical status were also improved in glucocorticoid group. CONCLUSIONS Limited data indicate that glucocorticoid therapy may be used safely in patients with ADHF in short term. Glucocorticoid therapy did not cause heart failure deterioration. Further investigations are warranted.
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Banh E, Wu WD, Rinehart J. Principles of pharmacologic hemodynamic management and closed-loop systems. Best Pract Res Clin Anaesthesiol 2014; 28:453-62. [PMID: 25480774 DOI: 10.1016/j.bpa.2014.08.004] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2014] [Revised: 08/25/2014] [Accepted: 08/29/2014] [Indexed: 01/30/2023]
Abstract
Every day, physicians in critical-care settings are challenged with the hemodynamic management of patients with severe cardiovascular derangements. There is a potential role for closed-loop (automated) systems to assist clinicians in managing these patients and growing interest in the possible applications. In this review, we discuss the basic principles of critical-care hemodynamic management and the closed-loop systems that have been developed to help in this setting.
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Affiliation(s)
- Esther Banh
- Department of Anesthesiology & Perioperative Care, University of California Irvine, Irvine, CA, USA
| | - Wei Der Wu
- Department of Anesthesiology & Perioperative Care, University of California Irvine, Irvine, CA, USA
| | - Joseph Rinehart
- Department of Anesthesiology & Perioperative Care, University of California Irvine, Irvine, CA, USA.
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Editor's picks, 2012–2013: sixteen articles in free access in Intensive Care Medicine. Intensive Care Med 2014. [DOI: 10.1007/s00134-014-3330-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
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Nieminen M, Altenberger J, Ben-Gal T, Böhmer A, Comin-Colet J, Dickstein K, Édes I, Fedele F, Fonseca C, García-González M, Giannakoulas G, Iakobishvili Z, Jääskeläinen P, Karavidas A, Kettner J, Kivikko M, Lund L, Matskeplishvili S, Metra M, Morandi F, Oliva F, Parkhomenko A, Parissis J, Pollesello P, Pölzl G, Schwinger R, Segovia J, Seidel M, Vrtovec B, Wikström G. Repetitive use of levosimendan for treatment of chronic advanced heart failure: Clinical evidence, practical considerations, and perspectives: An expert panel consensus. Int J Cardiol 2014; 174:360-7. [DOI: 10.1016/j.ijcard.2014.04.111] [Citation(s) in RCA: 43] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/08/2014] [Revised: 03/14/2014] [Accepted: 04/09/2014] [Indexed: 01/19/2023]
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Pierrakos C, Velissaris D, Franchi F, Muzzi L, Karanikolas M, Scolletta S. Levosimendan in critical illness: a literature review. J Clin Med Res 2014; 6:75-85. [PMID: 24578748 PMCID: PMC3935527 DOI: 10.14740/jocmr1702w] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/12/2013] [Indexed: 01/30/2023] Open
Abstract
Levosimendan, the active enantiomer of simendan, is a calcium sensitizer developed for treatment of decompensated heart failure, exerts its effects independently of the beta adrenergic receptor and seems beneficial in cases of severe, intractable heart failure. Levosimendan is usually administered as 24-h infusion, with or without a loading dose, but dosing needs adjustment in patients with severe liver or renal dysfunction. Despite several promising reports, the role of levosimendan in critical illness has not been thoroughly evaluated. Available evidence suggests that levosimendan is a safe treatment option in critically ill patients and may reduce mortality from cardiac failure. However, data from well-designed randomized controlled trials in critically ill patients are needed to validate or refute these preliminary conclusions. This literature review is an attempt to synthesize available evidence on the role and possible benefits of levosimendan in critically ill patients with severe heart failure.
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Affiliation(s)
- Charalampos Pierrakos
- Department of Intensive Care, Universite Catholique de Louvain, Mont-Godinne University Hospital, Yvoir 5530, Belgium
| | - Dimitrios Velissaris
- Department of Internal Medicine, University of Patras School of Medicine, Patras, Greece
| | - Federico Franchi
- Department of Medical Biotechnologies, University of Siena, Siena, Italy
| | - Luigi Muzzi
- Department of Medical Biotechnologies, University of Siena, Siena, Italy
| | - Menelaos Karanikolas
- Department of Anesthesiology, Washington University School of Medicine, Campus Box 8054, 660 S. Euclid Avenue, St. Louis, MO, USA
| | - Sabino Scolletta
- Department of Medical Biotechnologies, University of Siena, Siena, Italy
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Affiliation(s)
- Joseph W. Rossano
- From the Cardiac Center, Children’s Hospital of Philadelphia, Philadelphia, PA; and Department of Pediatrics, Perelman School of Medicine, University of Pennsylvania, Philadelphia
| | - Robert E. Shaddy
- From the Cardiac Center, Children’s Hospital of Philadelphia, Philadelphia, PA; and Department of Pediatrics, Perelman School of Medicine, University of Pennsylvania, Philadelphia
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