51
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Najam O, Yonan N, Williams SG, Shaw SM. The usefulness of chronic heart failure treatments in chronic cardiac graft failure. Cardiovasc Ther 2010; 28:48-58. [PMID: 20074259 DOI: 10.1111/j.1755-5922.2009.00125.x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
Following cardiac transplantation, registry data has demonstrated a gradual improvement in survival over the last several decades, which is testament to continual improvement in aftercare strategy. However, a significant number of patients will eventually develop a new syndrome of chronic heart failure, owing to the multitude of physiological processes that occur after transplantation. This condition, referred to as chronic graft failure (CGF) should be regarded as a unique illness rather than one that is simply analogous with chronic heart failure. In particular, the unique pathophysiological (and pharmacological) environment in the setting of CGF presents a challenging situation to the transplant physician. There is uncertainty over which treatments to offer given a paucity of clinical trial data to support the use of standard heart failure treatments in CGF. In this review, we discuss which chronic heart failure treatments could be considered in the setting of CGF based on their mechanisms of action, benefits within the native heart failure setting, and the relevant issues within the posttransplant environment.
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Affiliation(s)
- Osman Najam
- North West Regional Heart Centre and Transplant Unit, University of South Manchester NHS Foundation Trust, Wythenshawe Hospital, Manchester M23 9LT, UK
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52
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Tsang S, Woo AYH, Zhu W, Xiao RP. Deregulation of RGS2 in cardiovascular diseases. Front Biosci (Schol Ed) 2010; 2:547-57. [PMID: 20036967 DOI: 10.2741/s84] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
Alteration of G protein-coupled receptor (GPCR) signaling is a salient feature of hypertension and the associated heart diseases. Recent studies have revealed a large family of Regulators of G-protein Signaling (RGS) proteins as important endogenous regulators of GPCR signaling. RGS2 selectively regulates Galphaq/11 signaling, an essential cause of hypertension and cardiac hypertrophy. Both clinical and animal studies have shown that deregulation of RGS2 leads to exacerbated Galphaq/11 signaling. There is an inverse correlation between RGS2 expression and blood pressure, as well as a selective down-regulation of RGS2 in various models of cardiac hypertrophy. The causal relationship has been established in animal studies. RGS2 knockout mice exhibit not only hypertension phenotype but also accelerated cardiac hypertrophy and heart failure in response to pressure-overload. Further in vitro studies have shown that RGS2 knockdown with RNA interference exacerbates, whilst RGS2 over-expression completely abolishes the Galphaq/11-induced hypertrophy. These findings indicate that deregulation of RGS2 plays a crucial role in the pathogenesis of cardiovascular diseases, marking RGS2 as a potential therapeutic target or biomarker of hypertension or hypertensive heart diseases.
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Affiliation(s)
- Sharon Tsang
- Laboratory of Cardiovascular Science, National Institute on Aging, Baltimore, MD 21224, USA
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53
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Opie LH, Knuuti J. The Adrenergic-Fatty Acid Load in Heart Failure. J Am Coll Cardiol 2009; 54:1637-46. [DOI: 10.1016/j.jacc.2009.07.024] [Citation(s) in RCA: 111] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/28/2009] [Revised: 07/15/2009] [Accepted: 07/27/2009] [Indexed: 12/19/2022]
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54
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Maurer MS, Sackner-Bernstein JD, El-Khoury Rumbarger L, Yushak M, King DL, Burkhoff D. Mechanisms Underlying Improvements in Ejection Fraction With Carvedilol in Heart Failure. Circ Heart Fail 2009; 2:189-96. [DOI: 10.1161/circheartfailure.108.806240] [Citation(s) in RCA: 54] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background—
Reductions in heart rate (HR) with β-blocker therapy have been associated with improvements in ejection fraction (EF). However, the relative contributions of HR reduction, positive inotropism, afterload reduction, and reverse remodeling to improvements in EF are unknown.
Methods and Results—
Twenty-nine patients (63�12 years old) with New York Heart Association class II-III heart failure underwent serial measurements of left ventricular volumes using 3-dimensional echocardiography and blood pressures by sphygmomanometry at baseline, 2 weeks, 2, 6, and 12 months after initiation of carvedilol. From these parameters, left ventricular contractility (indexed by the end-systolic pressure-volume ratio), total peripheral resistance, and effective arterial elastance (E
a
) were derived. Overall, EF increased by 7-percentage points after 6 months of therapy (from 25�9 to 32�9,
P
<0.0001). This change was due to an increase in stroke volume (
P
<0.001) with no significant change in end-diastolic volume (
P
=0.15). The EF change correlated with increased contractility, decreased HR and decreased total peripheral resistance (
P
<0.003 in each case). In those patients whose EF increased at least 5 points, ≈60% of the increase was due to HR reduction, ≈30% was due to increased contractility, and <20% was due to the decrease in total peripheral resistance.
Conclusions—
Decreased HR, improved chamber contractility and afterload reduction each contributed significantly to improved EF with carvedilol.
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Affiliation(s)
- Mathew S. Maurer
- From the Division of Cardiology (M.S.M, L.E.R., M.Y., D.L.K., D.B.), Columbia Presbyterian Medical Center, New York, NY; and Clinilabs (J.D.S.-B.), NY
| | - Jonathan D. Sackner-Bernstein
- From the Division of Cardiology (M.S.M, L.E.R., M.Y., D.L.K., D.B.), Columbia Presbyterian Medical Center, New York, NY; and Clinilabs (J.D.S.-B.), NY
| | - Lyna El-Khoury Rumbarger
- From the Division of Cardiology (M.S.M, L.E.R., M.Y., D.L.K., D.B.), Columbia Presbyterian Medical Center, New York, NY; and Clinilabs (J.D.S.-B.), NY
| | - Madeline Yushak
- From the Division of Cardiology (M.S.M, L.E.R., M.Y., D.L.K., D.B.), Columbia Presbyterian Medical Center, New York, NY; and Clinilabs (J.D.S.-B.), NY
| | - Donald L. King
- From the Division of Cardiology (M.S.M, L.E.R., M.Y., D.L.K., D.B.), Columbia Presbyterian Medical Center, New York, NY; and Clinilabs (J.D.S.-B.), NY
| | - Daniel Burkhoff
- From the Division of Cardiology (M.S.M, L.E.R., M.Y., D.L.K., D.B.), Columbia Presbyterian Medical Center, New York, NY; and Clinilabs (J.D.S.-B.), NY
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55
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Frankenstein L, Zugck C, Schellberg D, Nelles M, Froehlich H, Katus H, Remppis A. Prevalence and prognostic significance of adrenergic escape during chronic beta-blocker therapy in chronic heart failure. Eur J Heart Fail 2009; 11:178-84. [PMID: 19168516 DOI: 10.1093/eurjhf/hfn028] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
AIMS Like aldosterone escape to ACE-inhibitors, adrenergic escape (AE) to beta-blockers appears conceivable in chronic heart failure (CHF), as generalized systemic neurohumoral activation has been described as the pathophysiological basis of this syndrome. The aim of this study was to examine the prevalence and prognostic value of AE with respect to different beta-blocker agents and doses. METHODS AND RESULTS This was a prospective, observational study of 415 patients with systolic CHF receiving chronic stable beta-blocker therapy. AE was defined by norepinephrine levels above the upper limit of normal. Irrespective of the individual beta-blocker agents used and the dose equivalent taken, the prevalence of AE was 31-39%. Norepinephrine levels neither correlated with heart rate (r=0.02; 95% CI: -0.08-0.11; P=0.74) nor were they related to underlying rhythm (P=0.09) or the individual beta-blocker agent used (P=0.87). The presence of AE was a strong and independent indicator of mortality (adjusted HR: 1.915; 95% CI: 1.387-2.645; chi2: 15.60). CONCLUSION We verified the presence of AE in CHF patients on chronic stable beta-blocker therapy, irrespective of the individual beta-blocker agent and the dose equivalent. As AE might indicate therapeutic failure, the determination of AE could help to identify those patients with CHF that might benefit from more aggressive treatment modalities. Heart rate, however, is not a surrogate for adrenergic escape.
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Affiliation(s)
- Lutz Frankenstein
- Department of Cardiology, Angiology, Pulmology, University of Heidelberg, 69120 Heidelberg, Germany.
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56
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Coronary Hemodynamics in Heart Failure and Effects of Therapeutic Interventions. J Card Fail 2009; 15:116-23. [DOI: 10.1016/j.cardfail.2009.01.001] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2008] [Revised: 01/07/2009] [Accepted: 01/13/2009] [Indexed: 11/19/2022]
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57
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Levine TB, Levine AB, Keteyian SJ, Narins B. The impact of beta-receptor blocker addition to high-dose angiotensin-converting enzyme inhibitor-nitrate therapy in heart failure. Clin Cardiol 2009; 21:899-904. [PMID: 9853182 PMCID: PMC6656245 DOI: 10.1002/clc.4960211208] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
BACKGROUND The natural history of heart failure is one of continued worsening of cardiac function. Beta-receptor blocker therapy has been effective in improving clinical status and left ventricular function in patients with heart failure. Similarly, high doses of angiotensin-converting enzyme (ACE) inhibitors with nitrates partially reverse the ventricular remodeling of heart failure. HYPOTHESIS We tested the hypothesis that beta-blocker therapy added to high-dose ACE inhibitor-nitrates would potentiate the reversal of heart failure. METHODS Thirteen patients, aged 52 +/- 8 years, with moderate to severe heart failure, 12 of whom were referred for transplant consideration, with heart failure duration of 4.8 +/- 2.2 years, were prospectively followed for 12 months. Baseline echocardiographic ejection fraction was 19 +/- 8%, and presenting New York Heart Association class was 2.9 +/- 0.7. Angiotensin-converting enzyme inhibitors and nitrates were uptitrated over 6 months to a final dose of lisinopril 53 +/- 31 mg/day, and isosorbide dinitrate 217 +/- 213 mg/day. At 6 months, beta-blocker therapy with atenolol was initiated and titrated to a final dose of 46 +/- 23 mg/day. Two-dimensional Doppler echocardiography and metabolic stress testing were performed at baseline, at 6 months on lisinopril-nitrates only, and at 12 months on combined ACE inhibitor-nitrate and beta-blocker therapy. RESULTS New York Heart Association classification improved from 2.9 +/- 0.7 to 1.8 +/- 0.8 on lisinopril-nitrates (p < 0.05), and to 1.5 +/- 0.5 with the addition of beta blockade (p = NS). On follow-up, peak oxygen consumption rose from 17 +/- 7 ml O2/kg/min at baseline to 21 +/- 5 ml O2/kg/min at 6 months on lisinopril-nitrates (p = 0.06) without further change on beta blockade. Ejection fraction rose from 19 +/- 8 to 33 +/- 14% on lisinopril-nitrates at 6 months (p = 0.005) and to 36 +/- 18% on beta blockade at 12 months (p = NS). CONCLUSION High-dose ACE inhibitor-nitrate therapy significantly improved patient clinical status and left ventricular systolic function in heart failure. The addition of beta-receptor blockade over and above high-dose ACE inhibitor-nitrates was well tolerated but had no further impact on symptomatic status, exercise tolerance, or left ventricular systolic function. The potential for pharmacologic reversal of heart failure remodeling may be finite despite the use of complementary therapies. Larger placebo-controlled and randomized trials of beta-receptor blockade added to high-dose ACE inhibitor-nitrate therapy are needed to confirm these observations.
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Affiliation(s)
- T B Levine
- Michigan Institute for Heart Failure and Transplant Care, Botsford General Hospital, Farmington Hills 48336, USA
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58
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Murphy NF, O'Loughlin C, Ledwidge M, McCaffrey D, McDonald K. Improvement but no cure of left ventricular systolic dysfunction in treated heart failure patients. Eur J Heart Fail 2008; 9:1196-204. [DOI: 10.1016/j.ejheart.2007.10.001] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/30/2007] [Accepted: 10/03/2007] [Indexed: 10/22/2022] Open
Affiliation(s)
- Niamh F. Murphy
- Heart Failure Unit, Department of Cardiology; St Vincent's University Hospital, and University College Dublin; Dublin 4 Ireland
| | - Christina O'Loughlin
- Heart Failure Unit, Department of Cardiology; St Vincent's University Hospital, and University College Dublin; Dublin 4 Ireland
| | - Mark Ledwidge
- Heart Failure Unit, Department of Cardiology; St Vincent's University Hospital, and University College Dublin; Dublin 4 Ireland
| | - Dermot McCaffrey
- Heart Failure Unit, Department of Cardiology; St Vincent's University Hospital, and University College Dublin; Dublin 4 Ireland
| | - Kenneth McDonald
- Heart Failure Unit, Department of Cardiology; St Vincent's University Hospital, and University College Dublin; Dublin 4 Ireland
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59
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Sharma V, Parsons H, Allard MF, McNeill JH. Metoprolol increases the expression of β3-adrenoceptors in the diabetic heart: Effects on nitric oxide signaling and forkhead transcription factor-3. Eur J Pharmacol 2008; 595:44-51. [DOI: 10.1016/j.ejphar.2008.07.042] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2008] [Revised: 07/09/2008] [Accepted: 07/23/2008] [Indexed: 10/21/2022]
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60
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Trimetazidine, a Metabolic Modulator, Has Cardiac and Extracardiac Benefits in Idiopathic Dilated Cardiomyopathy. Circulation 2008; 118:1250-8. [DOI: 10.1161/circulationaha.108.778019] [Citation(s) in RCA: 181] [Impact Index Per Article: 11.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background—
The anti-ischemic agent trimetazidine improves ejection fraction in heart failure that is hypothetically linked to inhibitory effects on cardiac free fatty acid (FFA) oxidation. However, FFA oxidation remains unmeasured in humans. We investigated the effects of trimetazidine on cardiac perfusion, efficiency of work, and FFA oxidation in idiopathic dilated cardiomyopathy.
Methods and Results—
Nineteen nondiabetic patients with idiopathic dilated cardiomyopathy on standard medication were randomized to single-blind trimetazidine (n=12) or placebo (n=7) for 3 months. Myocardial perfusion, FFA, and total oxidative metabolism were measured using positron emission tomography with [
15
O]H
2
O, [
11
C]acetate, and [
11
C]palmitate. Cardiac function was assessed echocardiographically; insulin sensitivity was assessed by the homeostasis model assessment index. Trimetazidine increased ejection fraction from 30.9±8.5% to 34.8±12% (
P
=0.027 versus placebo). Myocardial FFA uptake was unchanged, and β-oxidation rate constant decreased only 10%. Myocardial perfusion, oxidative metabolism, and work efficiency remained unchanged. Trimetazidine decreased insulin resistance (glucose: 5.9±0.7 versus 5.5±0.6 mmol/L,
P
=0.047; insulin: 10±6.9 versus 7.6±3.6 mU/L,
P
=0.031; homeostasis model assessment index: 2.75±2.28 versus 1.89±1.06,
P
=0.027). The degree of β-blockade and trimetazidine interacted positively on ejection fraction. Plasma high-density lipoprotein concentrations increased 11% (
P
<0.001).
Conclusions—
In idiopathic dilated cardiomyopathy with heart failure, trimetazidine increased cardiac function and had both cardiac and extracardiac metabolic effects. Cardiac FFA oxidation modestly decreased and myocardial oxidative rate was unchanged, implying increased oxidation of glucose. Trimetazidine improved whole-body insulin sensitivity and glucose control in these insulin-resistant idiopathic dilated cardiomyopathy patients, thus hypothetically countering the myocardial damage of insulin resistance. Additionally, the trimetazidine-induced increase in ejection fraction was associated with greater β1-adrenoceptor occupancy, suggesting a synergistic mechanism.
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61
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Impaired energetics in heart failure — A new therapeutic target. Pharmacol Ther 2008; 119:264-74. [DOI: 10.1016/j.pharmthera.2008.05.007] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2008] [Accepted: 05/09/2008] [Indexed: 11/20/2022]
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62
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Nuttall SL, Langford NJ, Kendall MJ. Beta-blockers in heart failure. 2. Mode of action. J Clin Pharm Ther 2008. [DOI: 10.1111/j.1365-2710.2001.00316.x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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63
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Flannery G, Gehrig-Mills R, Billah B, Krum H. Analysis of randomized controlled trials on the effect of magnitude of heart rate reduction on clinical outcomes in patients with systolic chronic heart failure receiving beta-blockers. Am J Cardiol 2008; 101:865-9. [PMID: 18328855 DOI: 10.1016/j.amjcard.2007.11.023] [Citation(s) in RCA: 149] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/05/2007] [Revised: 11/01/2007] [Accepted: 11/01/2007] [Indexed: 11/15/2022]
Abstract
Beta blockers improve cardiac function and prolong survival in patients with systolic chronic heart failure (CHF). However, the exact mechanisms underlying these benefits are uncertain. Specifically, it is unclear whether a close relation exists between heart rate (HR) reduction and clinical outcomes with these agents. This hypothesis was therefore tested within randomized controlled trials of beta blockers in systolic CHF. Left ventricular ejection fraction (LVEF) and HR values at baseline and study end were obtained from available beta-blocker randomized clinical trials. The relation between change in HR and all-cause mortality as well as the LVEF was determined using regression analysis. Thirty-five trials, which included 22,926 patients with a mean follow-up duration of 9.6 months, were analyzed for all-cause mortality, the LVEF, and HR. There was a close relation between all-cause annualized mortality rate and HR (adjusted R2 = 0.51, p = 0.004). A strong correlation between change in HR and change in LVEF (adjusted R2 = 0.48, p = 0.000) was also observed. When only trials with >100 patients were included, an even tighter correlation was seen (adjusted R2 = 0.60, p = 0.0004). In conclusion, these analyses indicate that a major contributor to the clinical benefits of beta-blocker therapy in systolic CHF may be the HR-lowering effect of these agents. Therefore, the magnitude of HR reduction may be more important than the achievement of target dose in beta-blocker treatment of systolic CHF.
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64
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Sharma V, Dhillon P, Wambolt R, Parsons H, Brownsey R, Allard MF, McNeill JH. Metoprolol improves cardiac function and modulates cardiac metabolism in the streptozotocin-diabetic rat. Am J Physiol Heart Circ Physiol 2008; 294:H1609-20. [PMID: 18203848 DOI: 10.1152/ajpheart.00949.2007] [Citation(s) in RCA: 51] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
The effects of diabetes on heart function may be initiated or compounded by the exaggerated reliance of the diabetic heart on fatty acids and ketones as metabolic fuels. beta-Blocking agents such as metoprolol have been proposed to inhibit fatty acid oxidation. We hypothesized that metoprolol would improve cardiac function by inhibiting fatty acid oxidation and promoting a compensatory increase in glucose utilization. We measured ex vivo cardiac function and substrate utilization after chronic metoprolol treatment and acute metoprolol perfusion. Chronic metoprolol treatment attenuated the development of cardiac dysfunction in streptozotocin (STZ)-diabetic rats. After chronic treatment with metoprolol, palmitate oxidation was increased in control hearts but decreased in diabetic hearts without affecting myocardial energetics. Acute treatment with metoprolol during heart perfusions led to reduced rates of palmitate oxidation, stimulation of glucose oxidation, and increased tissue ATP levels. Metoprolol lowered malonyl-CoA levels in control hearts only, but no changes in acetyl-CoA carboxylase phosphorylation or AMP-activated protein kinase activity were observed. Both acute metoprolol perfusion and chronic in vivo metoprolol treatment led to decreased maximum activity and decreased sensitivity of carnitine palmitoyltransferase I to malonyl-CoA. Metoprolol also increased sarco(endo)plasmic reticulum Ca(2+)-ATPase expression and prevented the reexpression of atrial natriuretic peptide in diabetic hearts. These data demonstrate that metoprolol ameliorates diabetic cardiomyopathy and inhibits fatty acid oxidation in streptozotocin-induced diabetes. Since malonyl-CoA levels are not increased, the reduction in total carnitine palmitoyltransferase I activity is the most likely factor to explain the decrease in fatty acid oxidation. The metabolism changes occur in parallel with changes in gene expression.
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Affiliation(s)
- Vijay Sharma
- Division of Pharmacology and Toxicology, Faculty of Pharmaceutical Sciences, Univ. of British Columbia, Vancouver, Canada
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65
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Frankenstein L, Nelles M, Slavutsky M, Schellberg D, Doesch A, Katus H, Remppis A, Zugck C. Beta-Blockers Influence the Short-term and Long-term Prognostic Information of Natriuretic Peptides and Catecholamines in Chronic Heart Failure Independent From Specific Agents. J Heart Lung Transplant 2007; 26:1033-9. [DOI: 10.1016/j.healun.2007.07.030] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2007] [Revised: 07/16/2007] [Accepted: 07/18/2007] [Indexed: 01/24/2023] Open
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66
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Knaapen P, Germans T, Knuuti J, Paulus WJ, Dijkmans PA, Allaart CP, Lammertsma AA, Visser FC. Myocardial Energetics and Efficiency. Circulation 2007; 115:918-27. [PMID: 17309938 DOI: 10.1161/circulationaha.106.660639] [Citation(s) in RCA: 143] [Impact Index Per Article: 8.4] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Affiliation(s)
- Paul Knaapen
- Department of Cardiology, 6D 120, VU University Medical Center, De Boelelaan 1117, 1081 HV, Amsterdam, The Netherlands.
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67
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Lopaschuk GD. Optimizing cardiac fatty acid and glucose metabolism as an approach to treating heart failure. Semin Cardiothorac Vasc Anesth 2007; 10:228-30. [PMID: 16959756 DOI: 10.1177/1089253206291150] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Despite the recent introduction of new therapeutic approaches to treat heart failure, mortality from heart failure remains high, and patients still frequently experience progression of contractile dysfunction and ongoing left ventricular enlargement. Therefore, new treatments are needed for heart failure that work independently of mechanisms already targeted. Emerging evidence suggests that the failure of the myocardium in heart failure is affected by alterations in the energy substrate metabolism. In particular, there is now evidence that in the failing heart, shifting metabolism away from a preference for fatty acids toward more carbohydrate oxidation can improve contractile function and slow the progression of pump failure.
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Affiliation(s)
- Gary D Lopaschuk
- Cardiovascular Research Group, University of Alberta, Edmonton, Alberta, Canada.
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68
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Chareonthaitawee P, Somers V. Continuous Positive Airway Pressure and Increased Ejection Fraction in Heart Failure and Obstructive Sleep Apnea. J Am Coll Cardiol 2007; 49:459-60. [PMID: 17258091 DOI: 10.1016/j.jacc.2006.10.041] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
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69
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Affiliation(s)
- Hani N Sabbah
- Department of Medicine, Division of Cardiovascular Medicine, Henry Ford Heart and Vascular Institute, Detroit, Michigan 48202, USA.
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70
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Abdulla J, Køber L, Christensen E, Torp-Pedersen C. Effect of beta-blocker therapy on functional status in patients with heart failure - A meta-analysis. Eur J Heart Fail 2006; 8:522-31. [PMID: 16376611 DOI: 10.1016/j.ejheart.2005.10.012] [Citation(s) in RCA: 34] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/28/2005] [Revised: 06/25/2005] [Accepted: 10/17/2005] [Indexed: 12/01/2022] Open
Abstract
BACKGROUND The results of randomised control trials (RCTs) evaluating the effect of beta-blockers on functional status in patients with chronic heart failure are conflicting. AIM To perform a systematic review and meta-analysis of RCTs evaluating the effect of beta-blockers on New York Heart Association (NYHA) classification and exercise tolerance in chronic heart failure. METHODS AND RESULTS We selected 28 RCTs evaluating beta-blocker versus placebo in addition to ACE inhibitor therapy. Combined results of 23 RCTs showed that beta-blockers improved NYHA class by at least one class with odds ratio (OR) 1.80 (1.33-2.43) p<0.0001. Meta-analysis of 10 RCTs showed a significant prolongation of exercise time by 44.19 (6.62-81.75) s p=0.021. Combining 8 RCTs evaluating the maximal peak oxygen uptake and 9 RCTs evaluating 6-min walk distance showed that beta-blockers had no significant effect compared with placebo, p=0.484, and p=0.730, respectively. Combined results of the 23 RCTs showed significant reducing effect on all cause mortality with OR=0.69 (0.59-0.82) p<0.0001. CONCLUSION Chronic use of a beta-blocker in conjunction with ACE inhibitor therapy improves dyspnoea and prolongs exercise tolerance time, but has no significant effect on 6-min walk test or maximal oxygen uptake in patients with heart failure.
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Affiliation(s)
- Jawdat Abdulla
- Department of Cardiology, Gentofte University Hospital, Copenhagen, Denmark.
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71
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Blume ED, Canter CE, Spicer R, Gauvreau K, Colan S, Jenkins KJ. Prospective single-arm protocol of carvedilol in children with ventricular dysfunction. Pediatr Cardiol 2006; 27:336-42. [PMID: 16596434 DOI: 10.1007/s00246-005-1159-1] [Citation(s) in RCA: 34] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
The objective of this study was to evaluate the safety and efficacy of carvedilol in pediatric patients with stable moderate heart failure. We performed a single-arm prospective drug trial at three academic medical centers and the results were compared to historical controls. Patients were 3 months to 17 years old with an ejection fraction <40% in the systemic ventricle for at least 3 months on maximal medical therapy including ACE inhibitors. Treated patients were started on 0.1 mg/kg/day and uptitrated to 0.8 mg/kg/day or the maximal tolerated dose. Echocardiographic parameters of function were prospectively measured at entry and at 6 months. Two composite endpoints were recorded: severe decline in status and significant clinical change. Adverse events were reviewed by a safety committee. Data were also collected from untreated controls with dilated cardiomyopathy meeting entry criteria, assessed over a similar time frame. Twenty patients [12 dilated cardiomyopathy (DCM) and 8 congenital] with a median age of 8.4 years (range, 8 months to 17.8 years) were treated with carvedilol. Three patients discontinued the drug during the study. At entry, there was no statistical difference in age, weight, or ejection fraction between the treated group and controls. The ejection fraction of the treated DCM group improved significantly from entry to 6 months (median, 31 to 40%, p = 0.04), with no significant change in ejection fraction in the control group [median, 29 to 27%, p = not significant (NS)]. The median increase in ejection fraction was larger for the treated DCM group than for the untreated DCM controls (7 vs 0%, p = 0.05). By Kaplan-Meier analysis, time to death or transplant tended to be longer in treated patients (p = 0.07). The difference in the proportion of patients with severe decline in status or significant clinical change in the treated group was not significant compared to the controls (5 vs 12%, p = NS). We conclude that in this prospective protocol of pediatric patients, the use of adjunct carvedilol in the DCM group improved ejection fraction compared to untreated controls and trended toward delaying time to transplant or death.
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Affiliation(s)
- E D Blume
- Department of Cardiology, Children's Hospital, Boston, 300 Longwood Avenue, Boston, MA 02115, USA.
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Nikolaidis LA, Poornima I, Parikh P, Magovern M, Shen YT, Shannon RP. The effects of combined versus selective adrenergic blockade on left ventricular and systemic hemodynamics, myocardial substrate preference, and regional perfusion in conscious dogs with dilated cardiomyopathy. J Am Coll Cardiol 2006; 47:1871-81. [PMID: 16682315 DOI: 10.1016/j.jacc.2005.11.082] [Citation(s) in RCA: 29] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/03/2005] [Revised: 11/28/2005] [Accepted: 11/30/2005] [Indexed: 12/16/2022]
Abstract
OBJECTIVES Given that adverse effects of chronic sympathetic activation are mediated by all three adrenergic receptor subtypes (beta1, beta2, alpha1), we examined the effects of standard doses of carvedilol and metoprolol succinate (metoprolol controlled release/extended release [CR/XL]) on hemodynamics, myocardial metabolism, and regional organ perfusion. BACKGROUND Both beta1 selective and combined adrenergic blockade reduce morbidity and mortality in heart failure. Whether there are advantages of one class over the other remains controversial, even in the wake of the Carvedilol Or Metoprolol European Trial (COMET). Similarly, the mechanistic basis for the relative differences is incompletely understood. METHODS Thirty-three conscious, chronically instrumented dogs with pacing-induced (240 min(-1) for 4 weeks) dilated cardiomyopathy (DCM) were randomized to carvedilol (25 mg twice daily, Coreg, Glaxo Smith Kline, Research Triangle, North Carolina) or metoprolol succinate (100 mg qd, Toprol XL, Astra Zeneca, Wilmington, Delaware). Left ventricular and systemic hemodynamics, myocardial substrate uptake, and norepinephrine spillover were measured before and after three days of treatment. Regional (renal, hepatic, skeletal muscle) blood flows were measured using neutron-activated microspheres. RESULTS Both agents had comparable heart rate effects. However, carvedilol-treated dogs showed significantly greater increases in stroke volume and cardiac output and decreases in left ventricular end-diastolic pressure and systemic vascular resistance. Carvedilol increased renal, hepatic, and skeletal muscle blood flow. Carvedilol increased myocardial glucose uptake and suppressed norepinephrine and glucagon. Carvedilol antagonized the response to exogenous norepinephrine to a greater extent than metoprolol CR/XL. CONCLUSIONS At doses inducing comparable heart rate reductions, short-term treatment with carvedilol had superior hemodynamic and metabolic effects compared with metoprolol CR/XL. These data suggest important advantages of blocking all three adrenergic receptor subtypes in DCM.
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Affiliation(s)
- Lazaros A Nikolaidis
- Department of Medicine, Allegheny General Hospital, Pittsburgh, Pennsylvania 15212, USA
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Zhang Q, Fung JWH, Auricchio A, Chan JYS, Kum LCC, Wu LW, Yu CM. Differential change in left ventricular mass and regional wall thickness after cardiac resynchronization therapy for heart failure. Eur Heart J 2006; 27:1423-30. [PMID: 16682380 DOI: 10.1093/eurheartj/ehi885] [Citation(s) in RCA: 42] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
AIMS LV reverse remodelling has been shown to be a favourable response after cardiac resynchronization therapy (CRT) in many clinical trials. This study investigated whether left ventricular (LV) reverse remodelling after CRT has any structural benefit, which include the improvement of LV mass or regional wall thickness. METHODS AND RESULTS Fifty patients (66 +/- 11 years) receiving CRT were followed up for at least 3 months. Echocardiography with tissue Doppler imaging was performed serially before and at day 1 and 3 months after CRT. Although LV end-systolic volume (LVESV) was decreased at day 1 after CRT (141 +/- 74 vs. 129 +/- 71 cm(3), P < 0.001), further LV reverse remodelling was observed at 3 months (110 +/- 67 cm(3), P < 0.001 vs. day 1). LV ejection fraction increased at day 1 (26.5 +/- 9.3 vs. 28.5 +/- 9.1%, P < 0.005) and was further improved at 3 months (34.2 +/- 10.5%, P < 0.001 vs. day 1). However, reduction of LV mass (231 +/- 67 vs. 213 +/- 59 g, P < 0.001) and regional wall thickness was only observed at 3 months, but not at day 1. The improvement of LV mass correlated with the change in LVESV (r = 0.66, P < 0.001) and the baseline systolic asynchrony index (Ts-SD) (r = -0.52, P < 0.001). LV mass was only decreased significantly in responders of LV reverse remodelling (245 +/- 66 vs. 207 +/- 61 g, P < 0.001), but increased in non-responders (209 +/- 64 vs. 223 +/- 56 g, P = 0.02). Responders had significant decrease in thickness of all the four walls for -6 to -11% (all P < or =0.02), whereas non-responders had increased thickness in septal and lateral walls for +11% (both P < 0.05). CONCLUSION The acute reduction in LV volume after CRT is mediated by haemodynamic and geometric benefits without actual changes in LV mass. However, at 3-month follow-up, reduction in LV mass and regional wall thickness was demonstrated, which represents structural reverse remodelling. Such benefit was only observed in volumetric responders but was worsened in non-responders.
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Affiliation(s)
- Qing Zhang
- Division of Cardiology, Department of Medicine and Therapeutics, Prince of Wales Hospital, SH Ho Cardiovascular and Stroke Centre, Institute of Vascular Medicine, The Chinese University of Hong Kong, Shatin, NT
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Nanas JN, Tsagalou EP, Nanas SN, Terrovitis JV, Tsolakis EJ, Toumanidis S, Papazoglou PD, Alexopoulos GP, Kanakakis J, Anastasiou-Nana MI. Reverse left ventricular remodeling by intermittent dobutamine infusions and amiodarone in end-stage heart failure due to idiopathic dilated cardiomyopathy. Int J Cardiol 2006; 108:237-43. [PMID: 16183152 DOI: 10.1016/j.ijcard.2005.05.010] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/26/2004] [Revised: 04/13/2005] [Accepted: 05/14/2005] [Indexed: 10/25/2022]
Abstract
BACKGROUND The aim of this study was to evaluate the long-term effect of combined intermittent dobutamine infusions (IDI) and oral amiodarone on reverse left ventricular (LV) remodeling and hemodynamics of patients with idiopathic dilated cardiomyopathy (IDC) and end-stage congestive heart failure (CHF). METHODS This non-randomized, prospective, clinical trial included sixteen consecutive patients suffering from dyspnea for a mean of 76+/-43 months, who presented with acute cardiac decompensation and were weaned from dobutamine therapy after an initial 72-h infusion. They were then placed on a regimen of oral amiodarone, 400 mg/day and weekly IDI, 10 microg/kg/min, for 8 h. The long-term clinical outcomes and the effects of treatment on reverse LV remodeling (echocardiographic parameters) and hemodynamics were evaluated at 3, 6, and 12 months of follow up. RESULTS A significant degree of reverse LV remodeling, hemodynamic improvements, and survivals >1.5 years were observed in 9 of the 16 patients (56%). In addition, 5 patients (31% of entire cohort) were weaned from IDI after a mean of 61+/-41 weeks, and 4 remained clinically stable for 116+/-66 weeks thereafter. At 12 months of follow-up, LV end-diastolic and end-systolic volume indices had decreased from 231+/-91 to 206+/-80 ml/m2 (P=0.002) and from 137+/-65 to 110+/-50 ml/m2 (P=0.003), respectively, right atrial pressure from 16+/-6 to 5.6+/-4 mm Hg, (P=0.031), and pulmonary capillary wedge pressure from 29+/-4 to 16+/-5.4 mm Hg, P=0.000, while LV ejection fraction had increased from 22+/-6% to 27.3+/-8% (P=0.006). CONCLUSIONS In end-stage CHF due to IDC, long-term treatment with IDI and oral amiodarone caused reverse LV remodeling, and allowed permanent and successful weaning from IDI in 1/4 of patients.
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Affiliation(s)
- John N Nanas
- University of Athens School of Medicine, Department of Clinical Therapeutics, Alexandra Hospital, Athens, Greece.
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Mobini R, Fu M, Jansson PA, Bergh CH, Scharin Täng M, Waagstein F, Andersson B. Influence of central inhibition of sympathetic nervous activity on myocardial metabolism in chronic heart failure: acute effects of the imidazoline I1-receptor agonist moxonidine. Clin Sci (Lond) 2006; 110:329-36. [PMID: 16209659 DOI: 10.1042/cs20050037] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Although β-adrenergic blockade is beneficial in heart failure, inhibition of central sympathetic outflow using moxonidine has been associated with increased mortality. In the present study, we studied the acute effects of the imidazoline-receptor agonist moxonidine on haemodynamics, NA (noradrenaline) kinetics and myocardial metabolism. Fifteen patients with CHF (chronic heart failure) were randomized to a single dose of 0.6 mg of sustained-release moxonidine or matching placebo. Haemodynamics, NA kinetics and myocardial metabolism were studied over a 2.5 h time period. There was a significant reduction in pulmonary and systemic arterial pressures, together with a decrease in cardiac index in the moxonidine group. Furthermore, there was a simultaneous reduction in systemic and cardiac net spillover of NA in the moxonidine group. Analysis of myocardial consumption of substrates in the moxonidine group showed a significant increase in non-esterified fatty acid consumption and a possible trend towards an increase in myocardial oxygen consumption compared with the placebo group (P=0.16). We conclude that a single dose of moxonidine (0.6 mg) in patients already treated with a β-blocker reduced cardiac and overall sympathetic activity. The finding of increased lipid consumption without decreased myocardial oxygen consumption indicates a lack of positive effects on myocardial metabolism under these conditions. We suggest this might be a reason for the failure of moxonidine to prevent deaths in long-term studies in CHF.
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Affiliation(s)
- Reza Mobini
- Wallenberg Laboratory for Cardiovascular Research, Cardiovascular Institute, Sahlgrenska University Hospital, Göteborg, Sweden
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Pires LA. Implantable devices for management of chronic heart failure: defibrillators and biventricular pacing therapy. Curr Opin Anaesthesiol 2006; 19:69-74. [PMID: 16547436 DOI: 10.1097/01.aco.0000192780.55269.98] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
PURPOSE OF REVIEW With chronic heart failure already an epidemic in the USA, its prevalence is expected to rise significantly in the future. Despite improved survival with pharmacologic therapy, the morbidity and mortality of patients with heart failure remain high. The purpose of this review, therefore, is to present recent data on the non-pharmacologic, device-based treatment of patients with chronic heart failure. RECENT FINDINGS The implantable cardioverter-defibrillator has become standard treatment for the prevention of sudden, arrhythmic death. Recent well-designed clinical trials have led to device-based therapy as an important component in the management of patients with systolic left ventricular dysfunction (resulting from both ischemic and non-ischemic etiologies) and symptomatic chronic heart failure. Implantable cardioverter-defibrillator therapy alone (without biventricular pacing) results in a significant reduction in the overall mortality of patients with mild and moderate heart failure. Biventricular pacing (or cardiac resynchronization therapy) with or without a back-up implantable cardioverter-defibrillator, compared with optimal pharmacologic therapy, improves symptoms, quality of life, exercise tolerance, left ventricular function, and the survival of patients with advanced heart failure, a left ventricular ejection fraction of 35% or less, and intraventricular conduction delays (QRS > 120 ms), although up to approximately 30% of patients do not respond to cardiac resynchronization therapy. Ongoing and planned studies should clarify which patients are most likely to respond to cardiac resynchronization therapy and elucidate its role in those with a normal (< 120 ms) QRS (approximately 70% of patients with heart failure). SUMMARY Device therapy (implantable cardioverter-defibrillator and cardiac resynchronization therapy) should be considered an integral, but adjunctive, part of the management of patients with chronic heart failure who are receiving appropriate medical therapy. The type of device used will depend on the individual patient's clinical characteristics.
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Affiliation(s)
- Luis A Pires
- Department of Medicine, St John Hospital and Medical Center, and Wayne State University School of Medicine, Detroit, Michigan 48236, USA.
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Rahko PS. An echocardiographic analysis of the long-term effects of carvedilol on left ventricular remodeling, systolic performance, and ventricular filling patterns in dilated cardiomyopathy. Echocardiography 2005; 22:547-54. [PMID: 16060890 DOI: 10.1111/j.1540-8175.2005.40057.x] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022] Open
Abstract
BACKGROUND The long-term clinical benefit of beta blockade is well recognized, but data quantifying long-term effects of beta blockade on remodeling of the left ventricle (LV) is limited. METHODS This consecutive series evaluates the long-term response of the LV to the addition of carvedilol to conventional therapy for dilated cardiomyopathy. There were 33 patients who had a LV ejection fraction <45%, LV enlargement and symptomatic heart failure. Quantitative Doppler echocardiography was performed at baseline 6, 12, 24, and 36 months after initiation of carvedilol to evaluate LV ejection fraction, LV volume, wall stress, mass, regional function, and diastolic performance. RESULTS Compared to baseline there was a significant and sustained reduction in end-systolic volume and end-systolic wall stress with a corresponding improvement in LV ejection fraction. The LV mass did not decline but relative wall thickness increased toward normal. An analysis of regional wall motion responses showed an improvement in all areas, particularly the apical, septal, and lateral walls that was significantly more frequent in patients with a nonischemic etiology. Filling patterns of the LV remained abnormal throughout the study but changed with therapy suggesting a decline in filling pressures. These changes were sustained for 3 years. CONCLUSION (1) The addition of carvedilol to conventional therapy for a dilated cardiomyopathy significantly improves LV ejection fraction and reduces LV end-systolic volume and wall stress for at least 3 years, (2) the response to 6 months of treatment predicts the long-term response, (3) the typical response is partial improvement of the LV, complete return to normal size, and function is uncommon, and (4) abnormalities of LV filling persist in virtually all patients throughout the course of treatment.
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Affiliation(s)
- Peter S Rahko
- Section of Cardiovascular Medicine, Department of Medicine, University of Wisconsin Medical School, Madison, Wisconsin 53792-3248, USA.
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Steenman M, Lamirault G, Le Meur N, Léger JJ. Gene expression profiling in human cardiovascular disease. Clin Chem Lab Med 2005; 43:696-701. [PMID: 16207127 DOI: 10.1515/cclm.2005.118] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Gene expression profiling studies in human diseases have allowed better understanding of pathophysiological processes. In addition, they may lead to the development of new clinical tools to improve diagnosis and prognosis of patients. Most of these studies have been successfully performed for human cancers. Inspired by these results, researchers in the cardiovascular field have also started using large-scale transcriptional analysis to better understand and classify human cardiovascular disease. Here we provide an overview of the literature revealing new cardiac disease markers and encouraging results for further development of the expression profiling strategy for future clinical applications in cardiology.
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Morooka T, Inoue T, Kotooka N, Fujimatsu D, Komatsu A, Uchida F, Yoshida K, Hashimoto S, Hikichi Y, Kato T, Node K. An appropriate indication for the initiation of beta-blocker therapy in dilated cardiomyopathy. Cardiology 2005; 105:61-6. [PMID: 16272814 DOI: 10.1159/000089295] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/17/2005] [Accepted: 08/02/2005] [Indexed: 11/19/2022]
Abstract
BACKGROUND Although long-term treatment with beta-blockers has been shown to improve morbidity and mortality in dilated cardiomyopathy (DCM), patient responses are heterogeneous. METHODS To establish the appropriate indication for the initiation of beta-blocker therapy, we retrospectively analyzed 38 DCM patients treated with beta-blockers (metoprolol or carvedilol) and examined differences in baseline profiles between patients who could continue the therapy (responders) and those who could not (non-responders). RESULTS In 13 non-responders, the duration from onset of symptoms to beta-blocker initiation was longer (p < 0.05), systolic blood pressure was lower (p < 0.001), serum sodium concentration was lower (p < 0.05), left ventricular posterior wall thickness was thinner (p < 0.05), left ventricular end-diastolic pressure was higher (p < 0.05) and left ventricular wall stress was lower (p < 0.05) than in 25 responders. In 19 patients receiving carvedilol, 5 non-responders showed higher levels of human atrial natriuretic peptide (p < 0.05) and brain natriuretic peptide (p < 0.01) than 13 responders. Discriminant analysis with a linear discriminant function showed the following equation predicted response to beta-blocker therapy: h = 0.004 x systolic blood pressure - 0.002 x brain natriuretic peptide + 0.667 (R2 = 0.67, p < 0.001). The probability of predicting the response was 94.1% with h > or = 0.5. CONCLUSION We conclude that h > or = 0.5 is the appropriate indication for the initiation of beta-blocker therapy in DCM.
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Affiliation(s)
- Toshifumi Morooka
- Department of Cardiovascular and Renal Medicine, Saga University Faculty of Medicine, Saga, Japan
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Abstract
Chronic heart failure is characterised by excess adrenergic activity that augurs a poor prognosis. The reasons for increased adrenergic activity are complex and incompletely understood. The circumstantial evidence relating increased activity to adverse outcome is powerful, but not yet conclusive. In normal subjects, autonomic control of the circulation is predominantly under the control of sympatho-inhibitory inputs from the arterial and cardiopulmonary baroreceptors, with a small input from the excitatory ergo- and chemo-receptors. In heart failure, the situation is reversed, with loss of the restraining input from the baroreceptors and an increase in the excitatory inputs, resulting in excessive adrenergic activity. The circumstantial evidence linking neuroendocrine activation with poor outcome coupled with the clinical success of inhibition of the renin-angiotensin-aldosterone system has long suggested that inhibition of adrenergic activity might be beneficial in heart failure. There is a number of potential ways of achieving this. Improved treatment of heart failure itself may reduce sympathetic drive. There is an interplay between angiotensin II, aldosterone and the sympathetic nervous system, and thus RAAS antagonists, such as angiotensin converting enzyme inhibitors and spironolactone could directly reduce sympathetic activation. Exercise rehabilitation may similarly reduce sympathetic activity.Recently, beta-adrenergic receptor antagonists have been conclusively shown to improve symptoms, reduce hospitalisations and increase survival. However, the demonstration that central reduction of sympathetic activity with agents such as moxonidine increases morbidity and mortality suggests that we do not properly understand the role of sympathetic activation in the pathophysiology of heart failure.
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Affiliation(s)
- A L Clark
- Department of Cardiology, Castle Hill Hospital, Castle Road, Cottingham, Hull, HU16 5JQ
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Stanley WC, Recchia FA, Lopaschuk GD. Myocardial substrate metabolism in the normal and failing heart. Physiol Rev 2005; 85:1093-129. [PMID: 15987803 DOI: 10.1152/physrev.00006.2004] [Citation(s) in RCA: 1406] [Impact Index Per Article: 74.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
The alterations in myocardial energy substrate metabolism that occur in heart failure, and the causes and consequences of these abnormalities, are poorly understood. There is evidence to suggest that impaired substrate metabolism contributes to contractile dysfunction and to the progressive left ventricular remodeling that are characteristic of the heart failure state. The general concept that has recently emerged is that myocardial substrate selection is relatively normal during the early stages of heart failure; however, in the advanced stages there is a downregulation in fatty acid oxidation, increased glycolysis and glucose oxidation, reduced respiratory chain activity, and an impaired reserve for mitochondrial oxidative flux. This review discusses 1) the metabolic changes that occur in chronic heart failure, with emphasis on the mechanisms that regulate the changes in the expression of metabolic genes and the function of metabolic pathways; 2) the consequences of these metabolic changes on cardiac function; 3) the role of changes in myocardial substrate metabolism on ventricular remodeling and disease progression; and 4) the therapeutic potential of acute and long-term manipulation of cardiac substrate metabolism in heart failure.
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Affiliation(s)
- William C Stanley
- Department of Physiology and Biophysics, School of Medicine, Case Western Reserve University, 10900 Euclid Ave., Cleveland, Ohio 44106-4970, USA.
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Al-Hesayen A, Azevedo ER, Floras JS, Hollingshead S, Lopaschuk GD, Parker JD. Selective versus nonselective β-adrenergic receptor blockade in chronic heart failure: differential effects on myocardial energy substrate utilization. Eur J Heart Fail 2005; 7:618-23. [PMID: 15921803 DOI: 10.1016/j.ejheart.2004.04.015] [Citation(s) in RCA: 37] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/14/2004] [Revised: 03/03/2004] [Accepted: 04/28/2004] [Indexed: 12/01/2022] Open
Abstract
BACKGROUND Non-selective and selective beta-blockers have been shown to improve outcomes in chronic heart failure (CHF). Recent data suggests the non-selective beta-blockers have a more favourable effect on outcomes than beta(1)-selective agents. We sought to examine the differential effects of non-selective versus selective beta-blockade on myocardial substrate utilization in patients with CHF. METHODS AND RESULTS Twenty-two patients with CHF were randomised to the non-selective beta-blocker carvedilol or the selective beta-blocker metoprolol (double-blind). Measurement of hemodynamics, arterial and coronary sinus free fatty acid (FFA) and lactate levels, and cardiac norepinephrine spillover (CANESP) were made before and after 4 months of therapy. In the carvedilol group (n=11), there was a significant reduction in myocardial FFA uptake (0.12+/-0.02 to 0.1+/-0.02 mmol/l, P<0.03). By contrast, in the metoprolol group (n=11) there was no change in myocardial FFA extraction. Carvedilol therapy tended to increase myocardial lactate extraction (0.24+/-0.05 to 0.35+/-0.08 mmol/l, P=0.08) while metoprolol therapy resulted in a trend in the opposite direction (0.18+/-0.03 to 0.11+/-0.04 mmol/l, P=0.09). The change in lactate extraction in the carvedilol group was significantly different from that in the metoprolol group (+0.11+/-0.06 vs. -0.09+/-0.04 mmol/l, P<0.01). Carvedilol treatment caused a significant reduction in CANESP while metoprolol had a neutral effect (-95+/-27 vs. 25+/-42 pmol/min, carvedilol vs. metoprolol P<0.03). CONCLUSION Carvedilol treatment caused a 20% reduction in myocardial free fatty acid extraction while metoprolol had a neutral effect. These differences are most probably related to the differential effects of these two agents on efferent cardiac sympathetic activity and may be relevant to the reported differential effects of these drugs on clinical outcomes.
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Affiliation(s)
- Abdul Al-Hesayen
- Division of Cardiology, Department of Medicine, Mount Sinai Hospital and University Health Network Hospitals, University of Toronto, 600 University Avenue, Suite 1609, Toronto, Ontario, Canada, M5G 1X5
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McBride BF, White CM. Critical differences among beta-adrenoreceptor antagonists in myocardial failure: debating the MERIT of COMET. J Clin Pharmacol 2005; 45:6-24. [PMID: 15601801 DOI: 10.1177/0091270004269841] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
In the United States, carvedilol and metoprolol (tartrate or succinate) are the most commonly employed beta-adrenoreceptor antagonists for the treatment of heart failure. However, use of these agents in patients with heart failure remains extremely low despite overwhelming evidence of their beneficial short- and long-term effects. Because the myocardial pathophysiology associated with heart failure involves not only beta-1 adrenoreceptors but also beta-2 and alpha-1 adrenoreceptors, this indicates a more complex disease process that may require pan-receptor antagonism to provide optimal clinical benefit. Relative to metoprolol (tartrate or succinate), carvedilol represents an extremely complex molecular entity that not only possesses the ability to antagonize all of the principle adrenoreceptors involved in heart failure but also reduces oxidative stress and provides an antiarrhythmic benefit independent of beta-adrenoreceptor antagonism. Taken together, an interesting pharmacologic premise for the superiority of carvedilol relative to metoprolol (tartrate) may exist, but the lack of clinical trials comparing an optimal dose of either extended-release metoprolol (ie, succinate) or immediate-release metoprolol (ie, tartrate) to carvedilol limits the clinical application of the pharmacologic differences between the agents.
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Affiliation(s)
- Brian F McBride
- Division of Clinical Pharmacology, College of Medicine, Vanderbilt University, Nashville, Tennessee, USA
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Abstract
The requirement of chemical energy in the form of ATP to support systolic and diastolic work of the heart is absolute. Because of its central role in cardiac metabolism and performance, the subject of this review on energetics in the failing heart is ATP. We briefly review the basics of myocardial ATP metabolism and describe how this changes in the failing heart. We present an analysis of what is now known about the causes and consequences of these energetic changes and conclude by commenting on unsolved problems and opportunities for future basic and clinical research.
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Affiliation(s)
- Joanne S Ingwall
- Brigham and Women's Hospital, Harvard Medical School, Boston, Mass, USA
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Cioffi G, Stefenelli C, Tarantini L, Opasich C. Chronic left ventricular failure in the community: Prevalence, prognosis, and predictors of the complete clinical recovery with return of cardiac size and function to normal in patients undergoing optimal therapy. J Card Fail 2004; 10:250-7. [PMID: 15190536 DOI: 10.1016/j.cardfail.2003.10.002] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
BACKGROUND Chronic heart failure (CHF) is a progressive process requiring complex therapeutic interventions. Recently, several trials documented the clinical improvement and regression of left ventricular (LV) remodeling and function in patients on optimized CHF treatment. Furthermore, some authors reported isolated cases of patients who apparently "healed" from CHF. The aim of the present study was to characterize the phenomenon of the normalization in clinical status and LV size and function in CHF patients. METHODS AND RESULTS We monitored the clinical and echocardiographic parameters of a large cohort of patients with CHF and LV ejection fraction <40% every 6 months for a mean period of 17 +/- 9 months. Twenty of 110 study patients (18%) normalized clinical status and LV size and ejection fraction at any time (mean time 13 +/- 6 months) during the follow up. Such condition, however, was subsequently lost in 11 patients. The normalization was predicted by the nonischemic etiology of CHF, arterial hypertension, absence of diabetes mellitus, carvedilol therapy, and the dose of carvedilol. CONCLUSIONS The normalization in clinical status and LV size and function is not infrequently observed in patients on optimal CHF therapy. It is predicted by a set of clinical variables and favored by beta-blocker therapy. At medium term, this condition fades in a significant portion of patients.
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Affiliation(s)
- Giovanni Cioffi
- Department of Cardiology, Villa Bianca Hospital, Trento, Italy
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Au DH, Udris EM, Curtis JR, McDonell MB, Fihn SD. Association between chronic heart failure and inhaled beta-2-adrenoceptor agonists. Am Heart J 2004; 148:915-20. [PMID: 15523327 DOI: 10.1016/j.ahj.2004.03.048] [Citation(s) in RCA: 46] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/24/2023]
Abstract
BACKGROUND Recent reports suggest an association between beta-agonists and the risk of incident chronic heart failure (CHF). We sought to examine the association between inhaled beta-agonists and risk of incident and nonincident heart failure. METHODS We performed a nested case-control study within the Ambulatory Care Quality Improvement Project (ACQUIP). Case subjects were defined as having had a hospitalization with a primary discharge diagnosis of CHF. Controls were randomly selected from the ACQUIP cohort. The exposure was the number of beta-agonist canisters filled in the 90 days before an index date. RESULTS After adjusting for potentially confounding factors, there appeared to be no association between the use of inhaled beta-agonists and the risk of heart failure (1-2 canisters per month, OR 1.3 [95% CI 0.9, 1.8], > or =3 canisters per month, 1.1 [95% CI 0.8, 1.6]). However, among the cohort that had a history of CHF, there appeared to be a dose-response association between the number of inhaled beta-agonists and the risk of hospitalization for chronic heart failure (1-2 canisters per month, adjusted OR 1.8 [95% CI 1.1, 3.0], > or =3 canisters per month, adjusted OR 2.1 [95% CI 1.2, 3.8]). CONCLUSION beta-Agonists did not appear to be associated with incident heart failure but were associated with risk of CHF hospitalization among those subjects with a previous CHF diagnosis. Although a causal relationship cannot be inferred from these findings, further research is warranted to determine the safety and effectiveness of inhaled beta-agonists for patients with CHF.
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Affiliation(s)
- David H Au
- Health Services Research and Development, Division of Pulmonary and Critical Care Medicine, VA Puget Sound Health Care System, Seattle, Wash 98108, USA.
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87
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Nemoto S, Razeghi P, Ishiyama M, De Freitas G, Taegtmeyer H, Carabello BA. PPAR-gamma agonist rosiglitazone ameliorates ventricular dysfunction in experimental chronic mitral regurgitation. Am J Physiol Heart Circ Physiol 2004; 288:H77-82. [PMID: 15345480 DOI: 10.1152/ajpheart.01246.2003] [Citation(s) in RCA: 31] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
Previously we reported that the beneficial effects of beta-adrenergic blockade in chronic mitral regurgitation (MR) were in part due to induction of bradycardia, which obviously affects myocardial energy requirements. From this observation we hypothesized that part of the pathophysiology of MR may involve faulty energy substrate utilization, which in turn might lead to potentially harmful lipid accumulation as observed in other models of heart failure. To explore this hypothesis, we measured triglyceride accumulation in the myocardia of dogs with chronic MR and then attempted to enhance myocardial metabolism by chronic administration of the peroxisome proliferator-activated receptor (PPAR)-gamma agonist rosiglitazone. Cardiac tissues were obtained from three groups of dogs that included control animals, dogs with MR for 3 mo without treatment, and dogs with MR for 6 mo that were treated with rosiglitazone (8 mg/day) for the last 3 mo of observation. Hemodynamics and contractile function (end-systolic stress-strain relationship, as measured by K index) were assessed at baseline, 3 mo of MR, and 6 mo of MR (3 mo of the treatment). Lipid accumulation in MR (as indicated by oil red O staining score and TLC analysis) was marked and showed an inverse correlation with the left ventricular (LV) contractility. LV contractility was significantly restored after PPAR therapy (K index: therapy, 3.01 +/- 0.11*; 3 mo MR, 2.12 +/- 0.34; baseline, 4.01 +/- 0.29; ANOVA, P = 0.038; *P < 0.05 vs. 3 mo of MR). At the same time, therapy resulted in a marked reduction of intramyocyte lipid. We conclude that 1) chronic MR leads to intramyocyte myocardial lipid accumulation and contractile dysfunction, and 2) administration of the PPAR-gamma agonist rosiglitazone ameliorates MR-induced LV dysfunction accompanied by a decline in lipid content.
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Affiliation(s)
- Shintaro Nemoto
- Department of Medicine, Houston Veterans Affairs Medical Center, 2002 Holcombe Blvd., Houston, TX 77030, USA
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88
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Nikolaidis LA, Trumble D, Hentosz T, Doverspike A, Huerbin R, Mathier MA, Shen YT, Shannon RP. Catecholamines restore myocardial contractility in dilated cardiomyopathy at the expense of increased coronary blood flow and myocardial oxygen consumption (MvO2cost of catecholamines in heart failure). Eur J Heart Fail 2004; 6:409-19. [PMID: 15182765 DOI: 10.1016/j.ejheart.2003.09.013] [Citation(s) in RCA: 16] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/03/2003] [Accepted: 09/15/2003] [Indexed: 11/30/2022] Open
Abstract
To investigate the metabolic cost of catecholamine use in heart failure, we administered intravenous dobutamine or norepinephrine to dogs with moderate and severe LV dysfunction until LV contractile function was restored to normal levels. Both drugs were associated with significant increases in myocardial O(2) consumption, increased coronary blood flow requirements and decreased myocardial mechanical efficiency. These mechanisms may contribute to the deleterious effects of catecholamines in heart failure.
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Affiliation(s)
- Lazaros A Nikolaidis
- Department of Medicine, Allegheny General Hospital, Drexel University College of Medicine, 320 E. North Avenue, Pittsburgh, PA 15212, USA
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89
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Abstract
Diabetes is a risk factor for coronary atherosclerosis, myocardial infarction, and ischemic cardiomyopathy. Insulin resistance is associated with left ventricular (LV) hypertrophy and hypertensive cardiomyopathy. Even in the absence of coronary artery disease or hypertension, "diabetic cardiomyopathy" can develop because of myocardial autonomic dysfunction or impaired coronary flow reserve. The relationship between insulin resistance and cardiomyopathy is bidirectional. Systemic and myocardial glucose uptake is compromised in heart failure independent of etiology. These abnormalities are associated with cellular deficits of insulin signaling. Insulin resistance in heart failure can be detrimental, because transcriptional shifts in metabolic gene expression favor glucose over fat as a substrate for high-energy phosphate production. Although preexisting diabetes accelerates this process of "metabolic death," insulin resistance can also develop secondary to cardiomyopathy-associated overabundance of neurohormones and cytokines. Insulin resistance and fatty acid excess are potential therapeutic targets in heart failure, striving for efficient myocardial substrate utilization. Peroxisome proliferator activator receptor gamma (PPARgamma) agonists are antidiabetic agents with antilipemic and insulin-sensitizing activity. Experimental studies suggest salutary effects in limiting infarct size, attenuating myocardial reperfusion injury, inhibiting hypertrophic signaling and vascular antiinflammatory actions through cytokine inhibition. However, clinical applicability in diabetic patients experiencing heart failure has been hampered because of increased edema and even fewer reports of exacerbation associated with these compounds. Evidence to date argues for peripheral mechanisms of edema unrelated to central hemodynamics. Nevertheless, they are currently contraindicated in New York Heart Association (NYHA) III-IV patients, particularly in combination with insulin. Investigations are underway to decipher mechanisms, risks, and benefits of PPARgamma agonists, as well as the role of the structurally related PPARalpha receptor on cardiovascular metabolism and function.
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Affiliation(s)
- Lazaros A Nikolaidis
- Division of Cardiology, Department of Medicine, Drexel University College of Medicine, Allegheny General Hospital, Pittsburgh, Pennsylvania 15212, USA
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90
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Hole T, Frøland G, Gullestad L, Offstad J, Skjaerpe T. Metoprolol CR/XL Improves Systolic and Diastolic Left Ventricular Function in Patients with Chronic Heart Failure. Echocardiography 2004; 21:215-23. [PMID: 15053783 DOI: 10.1111/j.0742-2822.2004.03102.x] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
AIMS To investigate whether metoprolol controlled release/extended release (CR/XL) once daily would improve diastolic and systolic left ventricular function in patients with chronic heart failure and decreased ejection fraction. METHODS In an echocardiographic substudy to the Metoprolol CR/XL Randomized Intervention Trial in Heart Failure (MERIT-HF), 66 patients were examined three times during a 12-month period blinded to treatment group, assessing left ventricular dimensions and ejection fraction, and Doppler mitral inflow parameters, all measured in a core laboratory. RESULTS In the metoprolol CR/XL group left ventricular ejection fraction increased from 0.26 to 0.31 (P = 0.009) after a mean observation period of 10.6 months, and deceleration time of the early mitral filling wave (E) increased from 189 to 246 ms (P = 0.0012), time velocity integral of E-wave increased from 8.7 to 11.2 cm (P = 0.018), and the duration of the late mitral filling wave (A) increased from 122 to 145 ms (P = 0.014). No significant changes were seen in the placebo group regarding any of these variables. CONCLUSION Metoprolol CR/XL once daily in addition to standard therapy improved both diastolic and systolic function in patients with chronic heart failure and decreased ejection fraction.
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Affiliation(s)
- Torstein Hole
- Section of Cardiology, Medical Department, Alesund Hospital, Norway.
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91
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Stolen KQ, Kemppainen J, Kalliokoski KK, Luotolahti M, Viljanen T, Nuutila P, Knuuti J. Exercise training improves insulin-stimulated myocardial glucose uptake in patients with dilated cardiomyopathy. J Nucl Cardiol 2004; 10:447-55. [PMID: 14569237 DOI: 10.1016/s1071-3581(03)00528-2] [Citation(s) in RCA: 17] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/14/2023]
Abstract
BACKGROUND The effects of exercise training on myocardial substrate utilization have not previously been studied in patients with idiopathic dilated cardiomyopathy and mild heart failure. METHODS AND RESULTS Myocardial glucose uptake was studied in 15 clinically stable patients with dilated cardiomyopathy (New York Heart Association class I-II, ejection fraction 34% +/- 8%) with the use of 2-[fluorine 18]fluoro-2-deoxy-d-glucose ([F-18]FDG) and positron emission tomography under euglycemic hyperinsulinemia. Eight of these patients participated in a 5-month endurance and strength training program, whereas seven patients served as nontrained subjects. Left ventricular function was assessed by 2-dimensional echocardiography before and after the intervention. After the training period, insulin-stimulated myocardial fractional [F-18]FDG uptake and glucose uptake rates were significantly increased in the anterior, lateral, and septal walls (P <.01) in the trained subjects but remained unchanged in the nontrained subjects. In the trained patients, whole-body insulin-stimulated glucose uptake was enhanced and serum free fatty acid levels were suppressed during hyperinsulinemia compared with the baseline study (P <.05). No changes were observed in the nontrained group. CONCLUSIONS These results indicate that exercise training in patients with dilated cardiomyopathy improves insulin-stimulated myocardial glucose uptake. This improvement in glucose uptake may be indicative of a switch in myocardial preference to a more energy-efficient substrate.
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Affiliation(s)
- Kira Q Stolen
- Turku PET Centre, University of Turku, Turku, Finland
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92
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Toyama T, Hoshizaki H, Seki R, Isobe N, Adachi H, Naito S, Oshima S, Taniguchi K. Efficacy of amiodarone treatment on cardiac symptom, function, and sympathetic nerve activity in patients with dilated cardiomyopathy: comparison with beta-blocker therapy. J Nucl Cardiol 2004; 11:134-41. [PMID: 15052244 DOI: 10.1016/j.nuclcard.2003.11.006] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
BACKGROUND Amiodarone, which is an antiarrhythmic drug used to treat life-threatening arrhythmias, is effective in patients with chronic heart failure. However, its effectiveness compared with beta-blockers has not yet been reported. METHODS AND RESULTS In 30 patients (mean age, 57 +/- 13 years) with dilated cardiomyopathy, we compared 15 patients receiving amiodarone (group A) with 15 patients receiving metoprolol (group B). Before and after 1 year of treatment, cardiac iodine 123 metaiodobenzylguanidine uptake was assessed from the total defect score, heart-to-mediastinum activity ratio based on delayed images, and washout rate. New York Heart Association class and echocardiographic left ventricular ejection fraction were also assessed. In both groups the total defect score decreased (from 25 +/- 11 to 16 +/- 10 in group A, P <.01; from 26 +/- 10 to 18 +/- 11 in group B, P <.01), the heart-to-mediastinum activity ratio increased (from 1.63 +/- 0.16 to 1.81 +/- 0.29 in group A, P <.01; from 1.63 +/- 0.21 to 1.85 +/- 0.3 in group B, P <.01), and the washout rate decreased (from 51% +/- 12% to 38% +/- 14% in group A, P <.01; from 48% +/- 11% to 37% +/- 8% in group B, P <.01). Left ventricular ejection fraction increased (from 30% +/- 9% to 42% +/- 11% in group A, P <.01; from 26% +/- 7% to 46% +/- 16% in group B, P <.01) and New York Heart Association functional class improved (from 3.1 +/- 0.5 to 1.8 +/- 0.7 in group A, P <.01; from 2.9 +/- 0.5 to 1.7 +/- 0.6 in group B, P <.01). CONCLUSION Amiodarone treatment can improve cardiac symptom, function, and sympathetic nerve activity, as evaluated by I-123 metaiodobenzylguanidine imaging in patients with dilated cardiomyopathy, which improves to a similar extent with beta-blocker treatment.
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Affiliation(s)
- Takuji Toyama
- Guma Prefectural Cardiovascular Center, Maebashi, Japan.
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93
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Packer M. Do β-blockers prolong survival in heart failure only by inhibiting the β1-receptor? A perspective on the results of the COMET trial. J Card Fail 2003; 9:429-43. [PMID: 14966782 DOI: 10.1016/j.cardfail.2003.08.003] [Citation(s) in RCA: 46] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
Experimental and clinical studies indicate that carvedilol exerts multiple antiadrenergic effects in addition to beta(1)-receptor blockade, but the prognostic importance of these actions has long been debated. This controversy has now been substantially advanced by the results of the recently completed Carvedilol Or Metoprolol European Trial (COMET), which showed that carvedilol (25 mg twice daily) reduced mortality by 17% when compared with metoprolol (50 mg twice daily), P=.0017--a result that was consistent with the differences seen across earlier controlled trials with beta-blockers in survivors of an acute myocardial infarction and in patients with chronic heart failure. Questions have been raised about the interpretation of these findings in view of the fact that the trial did not use the dose or formulation of metoprolol that was shown to prolong life in a placebo-controlled trial (ie, Metoprolol CR/XL [Controlled Release] Randomized Intervention Trial in Heart Failure). Pharmacokinetic and pharmacodynamic analyses, however, indicate that the dosing regimen of metoprolol selected for use in the COMET trial produces a magnitude and time course of beta(1)-blockade during a 24-hour period that is similar to the dose of carvedilol targeted for use in the trial. These analyses suggest that the observed difference in the mortality effects of metoprolol and carvedilol is not related to a difference in the magnitude or time course of their beta(1)-blocking effects but instead reflect antiadrenergic effects of carvedilol in addition to beta(1)-blockade.
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Affiliation(s)
- Milton Packer
- Division of Circulatory Physiology, Columbia University College of Physicians and Surgeons, New York, New York 10032, USA
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94
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Eichhorn EJ, Grayburn PA, Mayer SA, St John Sutton M, Appleton C, Plehn J, Oh J, Greenberg B, DeMaria A, Frantz R, Krause-Steinrauf H. Myocardial Contractile Reserve by Dobutamine Stress Echocardiography Predicts Improvement in Ejection Fraction With β-Blockade in Patients With Heart Failure. Circulation 2003; 108:2336-41. [PMID: 14597587 DOI: 10.1161/01.cir.0000097111.00170.7b] [Citation(s) in RCA: 57] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background—
β-Blockers improve survival and reduce hospitalization in chronic heart failure (CHF) by biologically improving left ventricular ejection fraction (LVEF). However, a good predictor of improvement with this therapy has not been identified. This substudy of BEST examined whether myocardial contractile reserve, as determined by dobutamine stress echocardiography, predicts improvement in LVEF.
Methods and Results—
Seventy-nine patients with class III/IV CHF underwent dobutamine stress echocardiography before treatment with bucindolol (n=41) or placebo (n=38). Regional wall motion score index (WMSI) was calculated as the sum of the scores in each segment divided by the total number of segments visualized. WMSI was compared with change in LVEF after 3 months of therapy as determined by gated radionuclide scan. Change in WMSI correlated inversely with change in LVEF after 3 months of bucindolol (
r
=−0.72,
P
<0.0001) and was the most significant multivariate predictor of change in LVEF (
P
=0.0002). Patients with contractile reserve had demographics similar to those of patients without contractile reserve, including RVEF, LVEF, systolic blood pressure, and CHF duration. However, patients without contractile reserve had higher baseline plasma norepinephrine levels (687±333 versus 420±246 pg/mL,
P
<0.05) and greater decrease in plasma norepinephrine in response to bucindolol (−249±171 versus −35±277 pg/mL,
P
<0.05).
Conclusions—
This study suggests a direct relationship between contractile reserve and improvement in LVEF with β-blocker therapy in patients with advanced CHF. Patients without contractile reserve have higher resting adrenergic drive, as reflected by plasma norepinephrine, and may experience greater sympatholytic effects from bucindolol.
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Affiliation(s)
- Eric J Eichhorn
- Department of Internal Medicine, Cardiology Division, the University of Texas Southwestern and Dallas VA Medical Centers, Dallas, USA.
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95
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Abstract
Beta-blockers, as determined by four landmark placebo-controlled studies, impart a significant survival advantage to the chronic heart failure population. What ancillary benefits might be expected from beta-blockade, in terms of symptom relief and improvement in exercise capacity, is less clear. This situation in part reflects the heterogeneity of tools used to quantify quality of life and exercise performance as well as factors concerning the statistical handling of symptom and exercise data. In this review we explore the methodology and results of over 20 trials of carvedilol, metoprolol and bisoprolol where quality of life and measures of exercise capacity were end-points. A consistent message relating to a benefit from beta-blockade on these outcomes was elusive but the finding that patients on beta-blockers did at least as well as patients prescribed placebo was a unanimous verdict. There remains a dearth of data to help identify those patients that are at high risk of adverse events from beta-blocker therapy.
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Affiliation(s)
- Aidan P Bolger
- Clinical Cardiology, National Heart and Lung Institute, Imperial College School of Science, Technology and Medicine, Dovehouse Street, London SW3 6LY, UK.
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96
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Plank DM, Yatani A, Ritsu H, Witt S, Glascock B, Lalli MJ, Periasamy M, Fiset C, Benkusky N, Valdivia HH, Sussman MA. Calcium dynamics in the failing heart: restoration by beta-adrenergic receptor blockade. Am J Physiol Heart Circ Physiol 2003; 285:H305-15. [PMID: 12649072 DOI: 10.1152/ajpheart.00425.2002] [Citation(s) in RCA: 37] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
Changes in calcium (Ca2+) regulation contribute to loss of contractile function in dilated cardiomyopathy. Clinical treatment using beta-adrenergic receptor antagonists (beta-blockers) slows deterioration of cardiac function in end-stage heart failure patients; however, the effects of beta-blocker treatment on Ca2+ dynamics in the failing heart are unknown. To address this issue, tropomodulin-overexpressing transgenic (TOT) mice, which suffer from dilated cardiomyopathy, were treated with a nonselective beta-receptor blocker (5 mg. kg-1. day-1 propranolol) for 2 wk. Ca2+ dynamics in isolated cardiomyocytes of TOT mice significantly improved after treatment compared with untreated TOT mice. Frequency-dependent diastolic and Ca2+ transient amplitudes were returned to normal in propranolol-treated TOT mice and but not in untreated TOT mice. Ca2+ kinetic measurements of time to peak and time decay of the caffeine-induced Ca2+ transient to 50% relaxation were also normalized. Immunoblot analysis of untreated TOT heart samples showed a 3.6-fold reduction of sarco(endo)plasmic reticulum Ca2+-ATPase (SERCA), whereas Na+/Ca2+ exchanger (NCX) concentrations were increased 2.6-fold relative to nontransgenic samples. Propranolol treatment of TOT mice reversed the alterations in SERCA and NCX protein levels but not potassium channels. Although restoration of Ca2+ dynamics occurred within 2 wk of beta-blockade treatment, evidence of functional improvement in cardiac contractility assessed by echocardiography took 10 wk to materialize. These results demonstrate that beta-adrenergic blockade restores Ca2+ dynamics and normalizes expression of Ca2+-handling proteins, eventually leading to improved hemodynamic function in cardiomyopathic hearts.
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Affiliation(s)
- David M Plank
- Divisions of Molecular Cardiovascular Biology, The Children's Hospital and Research Foundation, Cincinnati, OH 45229, USA
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97
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Au DH, Udris EM, Fan VS, Curtis JR, McDonell MB, Fihn SD. Risk of mortality and heart failure exacerbations associated with inhaled beta-adrenoceptor agonists among patients with known left ventricular systolic dysfunction. Chest 2003; 123:1964-9. [PMID: 12796175 DOI: 10.1378/chest.123.6.1964] [Citation(s) in RCA: 97] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
Abstract
OBJECTIVES Recent studies suggest that myocardial beta(2)-adrenoceptors may be important in chronic heart failure. We sought to determine if use of selective beta(2)-agonists was associated with hospitalization for heart failure and all-cause mortality. METHODS We studied a cohort of patients with left ventricular systolic dysfunction (LVSD). The outcome was the first hospitalization with a primary diagnosis of chronic heart failure or death from any cause. The exposure was the average number of beta-agonist canisters filled per month in the 90 days prior to and 15 days after enrollment. RESULTS Among 1,529 subjects, the relative risk (RR) of chronic heart failure hospital admission associated with inhaled beta-agonists followed a dose-response relationship: RR for one canister per month, 1.4 (95% confidence interval [CI], 0.9 to 2.0), RR for two canisters per month, 1.7 (95% CI, 1.2 to 2.5), and RR for three canisters per month, 2.1 (95% CI, 1.4 to 3.1). The RR of death demonstrated a similar finding: RR for one canister per month, 0.9 (95% CI, 0.5 to 1.5), RR for two canisters per month, 1.3 (95% CI, 0.9 to 2.1), and RR for three canisters per month, 2.0 (95% CI, 1.3 to 3.1). Adjusting for potential confounding factors did not affect the estimates. CONCLUSION Among subjects with LVSD, inhaled beta-agonists were associated with an increased risk of heart failure hospitalization, and all-cause mortality. Clinicians should carefully consider the etiology of dyspnea when prescribing beta-agonists to patients with LVSD.
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Affiliation(s)
- David H Au
- Health Services Research and Development, Northwest Center of Excellence, VA Puget Sound Health Care System, Department of Veterans Affairs, Seattle, WA 98108, USA.
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98
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Shekelle PG, Rich MW, Morton SC, Atkinson CSW, Tu W, Maglione M, Rhodes S, Barrett M, Fonarow GC, Greenberg B, Heidenreich PA, Knabel T, Konstam MA, Steimle A, Warner Stevenson L. Efficacy of angiotensin-converting enzyme inhibitors and beta-blockers in the management of left ventricular systolic dysfunction according to race, gender, and diabetic status: a meta-analysis of major clinical trials. J Am Coll Cardiol 2003; 41:1529-38. [PMID: 12742294 DOI: 10.1016/s0735-1097(03)00262-6] [Citation(s) in RCA: 332] [Impact Index Per Article: 15.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVES This study sought to assess the effect of angiotensin-converting enzyme (ACE) inhibitors and beta-blockers on all-cause mortality in patients with left ventricular (LV) systolic dysfunction according to gender, race, and the presence of diabetes. BACKGROUND Major randomized clinical trials have established that ACE inhibitors and beta-blockers have life-saving benefits in patients with LV systolic dysfunction. Most patients enrolled in these trials were Caucasian men. Whether an equal effect is achieved in women, non-Caucasians, and patients with major comorbidities has not been established. METHODS The authors performed a meta-analysis of published and individual patient data from the 12 largest randomized clinical trials of ACE inhibitors and beta-blockers to produce random effects estimates of mortality for subgroups. RESULTS Data support beneficial reductions in all-cause mortality for the use of beta-blockers in men and women, the use of ACE inhibitors and some beta-blockers in black and white patients, and the use of ACE inhibitors and beta-blockers in patients with or without diabetes. Women with symptomatic LV systolic dysfunction probably benefit from ACE inhibitors, but women with asymptomatic LV systolic dysfunction may not have reduced mortality when treated with ACE inhibitors (pooled relative risk = 0.96; 95% confidence interval: 0.75 to 1.22). The pooled estimate of three beta-blocker studies supports a beneficial effect in black patients with heart failure, but one study assessing bucindolol reported a nonsignificant increase in mortality. CONCLUSIONS Angiotensin-converting enzyme inhibitors and beta-blockers provide life-saving benefits in most of the subpopulations assessed. Women with asymptomatic LV systolic dysfunction may not achieve a mortality benefit when treated with ACE inhibitors.
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Affiliation(s)
- Paul G Shekelle
- Southern California Evidence-Based Practice Center, RAND Health, Santa Monica, California 90407-2138, USA.
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99
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Abstract
In multiple clinical trials, beta-blockers have been shown to significantly improve morbidity and mortality in adults with chronic congestive heart failure, but there is little reported experience with their use in children. Heart failure involves activation of the adrenergic nervous system and other neurohumoral systems in order to maintain cardiovascular homeostasis. These compensatory mechanisms have been shown to cause myocardial damage with chronic activation, which has been hypothesized to be a major contributing factor to the clinical deterioration of adults with heart failure. Studies have demonstrated inhibition of this neurohumoral response and concomitant clinical benefits with beta-blockers. Consequently, beta-blockers have evolved to become an important part of comprehensive medical therapy for congestive heart failure in adults. Pediatric heart failure represents an entirely different spectrum of disease, caused more commonly by congenital heart disease than cardiomyopathy. Surgical palliation and correction are important components of pediatric heart failure therapy, and residual, postsurgical cardiac lesions can lead to chronic heart failure. Although neurohumoral activation in children is similar to that in adults with heart failure, there are important differences from adults in physiology and developmental changes that are especially observed in infants. Current published clinical experience with beta-blocker use in children with heart failure is limited to case series with relatively small numbers of patients. Nevertheless, these series show consistent symptomatic improvement, and improvement in ventricular systolic function in patients with cardiomyopathies and congenital heart disease, similar to findings in adults. Adverse effects were common and many patients in these studies had adverse outcomes (death and/or need for transplantation). One study has noted differences in pharmacokinetics in children compared with adults. However, a multicenter, randomized controlled trial to evaluate carvedilol in pediatric heart failure from systolic ventricular dysfunction is currently ongoing and should help to clarify the efficacy and tolerability of carvedilol in children.
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Affiliation(s)
- Luke A Bruns
- Department of Pediatrics, Division of Pediatric Cardiology, Children's Heart Center of St Louis, St John's Mercy Medical Center, St Louis, MO, USA
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100
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Abstract
Although pharmacologic therapy has made impressive advances in the past decade and is the mainstay of therapy for heart failure (HF), there is still a large unmet need, because morbidity and mortality remain unacceptably high. Implanted medical devices are gaining increasing utility in this group of patients and have the potential to revolutionize the treatment of HF. The majority of devices in clinical use or under active investigation in HF can be grouped into 1 of 4 categories: devices to monitor the HF condition, devices to treat rhythm disturbances, devices to improve the mechanical efficiency of the heart, and devices to replace part or all of the heart's function. There are several devices either approved or under development to monitor the HF condition, ranging from interactive weight scales to implantable continuous pressure monitors. The challenge is to demonstrate that this technology can improve patient outcomes. Pacemakers and implantable cardioverter defibrillators (ICDs) are used to treat heart rhythms in a broad range of patients with heart disease, but they now have a special place in HF management with the prophylactic use of ICDs in patients who have advanced systolic dysfunction. The Multicenter Automatic Defibrillator Implantation Trial (MADIT) II study demonstrated a 29% reduction in all-cause mortality with ICDs in patients with a history of a myocardial infarction and a left ventricular (LV) ejection fraction <0.30. LV and multisite pacing are means of improving the mechanical efficiency of the heart. The concept is to create a more coordinated contraction of the ventricles to overcome the inefficiency associated with conduction system delays, which are common in HF. The acute hemodynamic effect can be impressive and is immediate. Several studies of intermediate duration (3 to 6 months) have consistently demonstrated that biventricular pacing improves symptoms and exercise capacity. Mechanical methods of remodeling the heart into a more efficient shape have been under scrutiny for several years. New methods of restraining the heart with prosthetic material are under investigation in humans, with encouraging pilot results. Heart replacement has been evaluated clinically with LV assist devices for several decades. The Randomized Evaluation of Mechanical Assistance Therapy as an Alternative in Congestive Heart Failure (REMATCH) study has demonstrated a proof of concept for the use of mechanical blood pumps to improve survival, functional capacity, and symptoms. Several assist devices with such features as total implantability, improved durability, and smaller size are now under study; these may further improve the outcomes of patients. One year ago, the world witnessed the first clinical use of a totally implantable total artificial heart. Although the long-term outcomes were limited, the device demonstrated an impressive ability to improve organ function and extend survival in the population facing imminent death. Further development in this field is expected. The use of devices in HF now has a strong foothold, and the potential exists for substantially greater use of a broad range of devices in the near future.
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Affiliation(s)
- John P Boehmer
- Division of Cardiology, Department of Medicine, Penn State University College of Medicine, Hershey Medical Center, Hershey, Pennsylvania 17033, USA.
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