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Núñez J, Sanchis J, Bodí V, Fonarow GC, Núñez E, Bertomeu-González V, Miñana G, Consuegra L, Bosch MJ, Carratalá A, Chorro FJ, Llàcer A. Improvement in risk stratification with the combination of the tumour marker antigen carbohydrate 125 and brain natriuretic peptide in patients with acute heart failure. Eur Heart J 2010; 31:1752-63. [PMID: 20501480 DOI: 10.1093/eurheartj/ehq142] [Citation(s) in RCA: 100] [Impact Index Per Article: 7.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/04/2023] Open
Abstract
AIM Elevated brain natriuretic peptide (BNP) and tumour marker antigen carbohydrate 125 (CA125) levels have shown to be associated with higher risk for adverse outcomes in patients with acute heart failure (AHF). Nevertheless, no attempt has been made to explore the utility of combining these two biomarkers. We sought to assess whether CA125 adds prognostic value to BNP in predicting 6-month all-cause mortality in patients with AHF. METHODS AND RESULTS We analysed 1111 consecutive patients admitted for AHF. Antigen carbohydrate 125 (U/mL) and BNP (pg/mL) were measured at a median of 72 +/- 12 h after instauration of treatment. Antigen carbohydrate 125 and BNP were dichotomized based on proposed prognostic cutpoints, and a variable with four categories was formed (BNP-CA125): C1 = BNP < 350 and CA125 < 60 (n = 394); C2 = BNP > or = 350 and CA125 < 60 (n = 165); C3 = BNP < 350 and CA125 > or = 60 (n = 331); and C4 = BNP > or = 350 and CA125 > or = 60 (n = 221). The independent association between BNP-CA125 and mortality was assessed with the Cox regression analysis, and their added predictive ability tested by the integrated discrimination improvement (IDI) index. At 6 months, 181 deaths (16.3%) were identified. The cumulative rate of mortality was lower for patients in C1 (7.8%), intermediate for C2 and C3 (17.8% and 16.9%, respectively), and higher for C4 (37.2%), and P-value for trend <0.001. After adjusting for established risk factors, the highest risk was observed when both biomarkers were elevated (C4 vs. C1: HR = 4.05, 95% CI = 2.54-6.45; P < 0.001) and intermediate when only one of them was elevated: (C2 vs. C1: HR = 1.71, 95% CI = 1.00-2.93; P = 0.050) and (C3 vs. C1: HR = 2.10, 95% CI = 1.30-3.39; P = 0.002). Moreover, when CA125 was added to the clinical model + BNP, a 10.4% (P < 0.0001) improvement in the IDI (on the relative scale) was found. CONCLUSION In patients admitted with AHF, CA125 added prognostic value beyond the information provided by BNP, and thus, their combination enables better 6-month risk stratification.
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Affiliation(s)
- Julio Núñez
- Servicio de Cardiología, Hospital Clínico Universitario, INCLIVA. Universitat de Valencia, Avda. Blasco Ibáñez 17., 46010 Valencia, Spain.
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DeWald TA, Hernandez AF. Efficacy and safety of nesiritide in patients with acute decompensated heart failure. Expert Rev Cardiovasc Ther 2010; 8:159-69. [PMID: 20136602 DOI: 10.1586/erc.09.173] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Acute decompensated heart failure is a common clinical problem with associated poor outcomes. Over the last decade, attention to this area has greatly increased, with a focus on medical therapies that may safely offer improvement in acute symptoms and early outcomes. Previous therapies that focused on increased inotropy have generally failed to improve symptoms without adverse consequences. Thus, attention towards vasodilators and natriuretic peptides, such as nesiritide, has increased owing to nesiritide's symptomatic improvement and unique mechanism of improvement in hemodynamics. However, the pathophysiology of acute decompensated heart failure is complex and the impact of nesiritide on important clinical end points, beyond symptomatic and hemodynamic improvement, is unknown.
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Affiliation(s)
- Tracy A DeWald
- Division of Clinical Pharmacology, Duke University Medical Center, Box 3943 Medical Center, Durham, NC 27710, USA.
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203
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Gheorghiade M, Follath F, Ponikowski P, Barsuk JH, Blair JE, Cleland JG, Dickstein K, Drazner MH, Fonarow GC, Jaarsma T, Jondeau G, Sendon JL, Mebazaa A, Metra M, Nieminen M, Pang PS, Seferovic P, Stevenson LW, van Veldhuisen DJ, Zannad F, Anker SD, Rhodes A, McMurray JJ, Filippatos G. Assessing and grading congestion in acute heart failure: a scientific statement from the Acute Heart Failure Committee of the Heart Failure Association of the European Society of Cardiology and endorsed by the European Society of Intensive Care Medicine. Eur J Heart Fail 2010; 12:423-33. [DOI: 10.1093/eurjhf/hfq045] [Citation(s) in RCA: 513] [Impact Index Per Article: 36.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/24/2022] Open
Affiliation(s)
- Mihai Gheorghiade
- Center for Cardiovascular Quality and Outcomes; Northwestern University Feinberg School of Medicine; Chicago IL USA
| | - Ferenc Follath
- Department of Medicine; University Hospital; Zürich Switzerland
| | | | - Jeffrey H. Barsuk
- Division of Hospital Medicine; Northwestern University Feinberg School of Medicine; Chicago IL USA
| | - John E.A. Blair
- Department of Cardiology; Wilford Hall Medical Center; San Antonio TX USA
| | - John G. Cleland
- Department of Academic Cardiology; University of Hull, Castle Hill Hospital; Hull UK
| | - Kenneth Dickstein
- Stavanger University Hospital; Stavanger Norway
- Institute of Internal Medicine; University of Bergen; Bergen Norway
| | - Mark H. Drazner
- University of Texas Southwestern Medical Center; Dallas TX USA
| | - Gregg C. Fonarow
- Division of Cardiology; University of California Los Angeles David Geffen School of Medicine; Los Angeles CA USA
| | - Tiny Jaarsma
- Department of Cardiology; University Hospital Groningen; Groningen The Netherlands
| | | | | | - Alexander Mebazaa
- Hospital Lariboisière; Paris France
- U942 INSERM; University Paris Diderot; Paris France
| | - Marco Metra
- Department of Cardiology; University of Brescia; Brescia Italy
| | - Markku Nieminen
- Department of Medicine, Section of Cardiology; Helsinki University Central Hospital; Helsinki Finland
| | - Peter S. Pang
- Department of Emergency Medicine and Center for Cardiovascular Quality and Outcomes; Northwestern University Feinberg School of Medicine; Chicago IL USA
| | - Petar Seferovic
- Department of Cardiology II; University Institute for Cardiovascular Diseases; Belgrade Serbia
| | | | | | - Faiez Zannad
- Department of Cardiology; Campus Virchow-Klinikum, Charité Universitätsmedizin; Berlin Germany
| | - Stefan D. Anker
- Department of Cardiology; Campus Virchow-Klinikum, Charité Universitätsmedizin; Berlin Germany
| | - Andrew Rhodes
- Department of Intensive Care Medicine; St George's Hospital; London UK
| | - John J.V. McMurray
- British Heart Foundation Cardiovascular Research Centre; University of Glasgow; Glasgow Scotland UK
| | - Gerasimos Filippatos
- Heart Failure Unit, Department of Cardiology; Athens University Hospital Attikon; Rimini 1 12461 Haidari Athens Greece
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204
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The critical link of hypervolemia and hyponatremia in heart failure and the potential role of arginine vasopressin antagonists. J Card Fail 2010; 16:419-31. [PMID: 20447579 DOI: 10.1016/j.cardfail.2009.12.021] [Citation(s) in RCA: 36] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2009] [Revised: 11/25/2009] [Accepted: 12/30/2009] [Indexed: 12/28/2022]
Abstract
BACKGROUND Hypervolemia and hyponatremia resulting from activation of the neurohormonal system and impairment of renal function are prominent features of decompensated heart failure. Both conditions share many pathophysiologic and prognostic features and each has been associated with increased morbidity and mortality. When both conditions coexist, therapeutic options are limited. METHODS AND RESULTS This review presents a concise digest of the pathophysiology, clinical significance, and pharmacological therapy of hyponatremia complicating heart failure with a special emphasis on vasopressin antagonists and their aquaretic effects in the absence of neurohormonal activation along with their ability to correct hyponatremia. CONCLUSIONS Hypervolemia and hyponatremia share many pathophysiologic and prognostic features in heart failure. Vasopressin antagonists provide a viable option for their management and a potentially unique role when both conditions coexists.
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205
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Papel activo de la congestión venosa en la fisiopatología de la insuficiencia cardiaca aguda descompensada. Rev Esp Cardiol 2010. [DOI: 10.1016/s0300-8932(10)70002-6] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
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206
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Biolo A, Rohde LE, Goldraich LA, Mascarenhas M, Palombini DV, Clausell N. Serum procollagen type III is associated with elevated right-sided filling pressures in stable outpatients with congestive heart failure. Biomarkers 2009; 14:438-42. [PMID: 19594402 DOI: 10.1080/13547500903098293] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
Elevated filling pressures are associated with heart failure deterioration, but mechanisms underlying this association remain poorly understood. We sought to investigate whether or not elevated filling pressures are associated with increased collagen turnover, evaluated by procollagen type III aminoterminal peptide (PIIINP) levels, in stable systolic heart failure. Eighty patients with heart failure with severe systolic dysfunction (ejection fraction 26 +/- 7%) were included. Patients underwent simultaneous echocardiogram with evaluation of haemodynamic parameters and blood sampling for PIIINP measurement. Mean PIIINP level was 6.11 +/- 2.62 microg l(-1). PIIINP was positively associated with estimated right atrial pressure (RAP) (r = 0.36; p = 0.001). Mean PIIINP values were 5.04 +/- 2.42 microg l(-1) in patients with estimated RAP < or = 5 mmHg, and 7.59 +/- 2.54 microg l(-1) in those with RAP > 15 mmHg (p < 0.01). In conclusion, elevated right-side filling pressures are associated with evidence of active extracellular matrix turnover, as indicated by elevated PIIINP levels, in stable systolic heart failure. Activation of extracellular matrix turnover may be implicated in the accelerated progression of heart failure syndromes seen in patients with persistent congestion.
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Affiliation(s)
- Andréia Biolo
- Division of Cardiology, Hospital de Clínicas de Porto Alegre, Post-graduate Program of Cardiovascular Sciences: Cardiology, Federal University of Rio Grande do Sul, Porto Alegre, Brazil
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Granger BB, Ekman I, Granger CB, Ostergren J, Olofsson B, Michelson E, McMurray JJ, Yusuf S, Pfeffer MA, Swedberg K. Adherence to medication according to sex and age in the CHARM programme. Eur J Heart Fail 2009; 11:1092-8. [DOI: 10.1093/eurjhf/hfp142] [Citation(s) in RCA: 84] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Affiliation(s)
- Bradi B. Granger
- Duke University Health System; Duke University School of Nursing; DUMC PO Box 3943 Durham NC 27710 USA
| | - Inger Ekman
- Sahlgrenska Academy at University of Gothenburg; Institute of Health and Care Sciences; Gothenburg Sweden
| | | | | | | | | | | | - Salim Yusuf
- Hamilton Health Sciences and University; Hamilton ON Canada
| | - Marc A. Pfeffer
- Harvard Medical School; Brigham and Women's Hospital; Boston MA USA
| | - Karl Swedberg
- Department of Emergency and Cardiovascular Medicine; Sahlgrenska University Hospital/Ostra, Goteborg/Sahlgrenska Academy at University of Gothenburg; Gothenburg Sweden
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208
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Bart BA. Treatment of congestion in congestive heart failure: ultrafiltration is the only rational initial treatment of volume overload in decompensated heart failure. Circ Heart Fail 2009; 2:499-504. [PMID: 19808381 DOI: 10.1161/circheartfailure.109.863381] [Citation(s) in RCA: 55] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Affiliation(s)
- Bradley A Bart
- Division of Cardiology, Hennepin County Medical Center, and the University of Minnesota, Minneapolis, Minn, USA.
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209
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Use of hand carried ultrasound, B-type natriuretic peptide, and clinical assessment in identifying abnormal left ventricular filling pressures in patients referred for right heart catheterization. J Card Fail 2009; 16:69-75. [PMID: 20123321 DOI: 10.1016/j.cardfail.2009.08.004] [Citation(s) in RCA: 40] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2008] [Revised: 05/27/2009] [Accepted: 08/13/2009] [Indexed: 12/13/2022]
Abstract
BACKGROUND The estimation of left ventricular filling pressure (LVFP) remains a critical component in the management of patients with known or suspected acute heart failure syndromes. Although right heart catheterization (RHC) remains the gold standard, several noninvasive parameters, including clinical assessment, B-type natriuretic peptides (BNP), and echocardiography can approximate LVFP. We sought to use a combination of these measures to noninvasively predict high or low LVFP in a population referred for RHC. METHODS AND RESULTS The study consisted of validation of hand-carried ultrasound (HCU)-derived measurement of mitral E/E' against standard echocardiograms in 50 patients, as well as direct comparison of jugular venous pressure (JVP), a clinical congestion score, HCU-derived E/E' and maximum inferior vena cava diameter (IVCmax), and BNP with pulmonary capillary wedge pressure (PCWP) in another 50 patients. The mean age was 61 years, ejection fraction 40%, JVP 9 cm, BNP 948 pg/mL, IVCmax 2.1 cm, E/E' 13, and PCWP 21. All parameters performed well in determining PCWP >or=15 mm Hg, with clinical score performing the worst (area under the receiver-operator characteristic curve [AUC] 0.74), and IVCmax performing the best (AUC 0.89). JVP, in combination with HCU-derived parameters and BNP performed better than any of the individual tests alone (AUC 0.97 for combination of all 3). CONCLUSIONS Clinical score, JVP, HCU indices, and BNP perform well at identifying patients with a PCWP >or=15 mm Hg. Use of these indices alone or in combination can be used to identify and potentially monitor patients with high LVFP in the inpatient and outpatient settings.
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210
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Pimenta J, Paulo C, Mascarenhas J, Gomes A, Azevedo A, Rocha-Gonçalves F, Bettencourt P. BNP at discharge in acute heart failure patients: is it all about volemia? A study using impedance cardiography to assess fluid and hemodynamic status. Int J Cardiol 2009; 145:209-214. [PMID: 19729213 DOI: 10.1016/j.ijcard.2009.08.001] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/09/2009] [Revised: 06/04/2009] [Accepted: 08/11/2009] [Indexed: 10/20/2022]
Abstract
BACKGROUND Besides hemodynamic parameters, several other variables have been associated to B-type natriuretic peptide (BNP) levels. Limited knowledge on BNP determinants in acute heart failure (HF) can undermine the interpretation of BNP levels. METHODS AND RESULTS To identify predictors of BNP levels, we evaluated 163 hospitalized acute HF patients. Thoracic fluid content (TFC) and hemodynamic parameters were measured by impedance cardiography at discharge. Patients were followed-up for 60 days for the occurrence of death/hospital admission. Median discharge BNP levels were 659.3 pg/ml. In multivariable linear regression analysis, TFC (β=0.043, 95% CI 0.024-0.062 per U/kΩ, p<0.001) was a powerful predictor of BNP levels, independently of known markers of HF severity like severe systolic dysfunction and discharge New York Heart Association class. Other independent predictors were: new onset HF, albumin, and body mass index. Sex, left cardiac work index, stroke index, hemoglobin, renal failure and discharge furosemide and lisinopril doses were associated to BNP only in univariate analysis. During follow-up, 45 (27.6%) patients were hospitalized or died. TFC (HR=1.047 (1.016-1.080) per U/kΩ increase, p=0.003) and BNP (HR=1.003 (1.001-1.004) per 10 pg/ml increase, p<0.001) were univariate predictors of the outcome, but in multivariate Cox regression analysis, only BNP was independently associated with prognosis. CONCLUSION Discharge BNP levels in acute HF patients reflected volemia and disease severity. Persistently high BNP levels during hospitalization should raise the possibility of remaining congestion, which could negatively influence prognosis. The utility of BNP as prognostic marker in HF may reside on its ability to reflect multiple underlying pathophysiological disturbances.
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Affiliation(s)
- Joana Pimenta
- Department of Internal Medicine, Hospital S. João, Porto, Portugal; Unit of Cardiovascular Research & Development, University of Porto Medical School, Porto, Portugal.
| | - Cristiana Paulo
- Department of Internal Medicine, Hospital S. João, Porto, Portugal; Unit of Cardiovascular Research & Development, University of Porto Medical School, Porto, Portugal
| | - Joana Mascarenhas
- Department of Internal Medicine, Hospital S. João, Porto, Portugal; Unit of Cardiovascular Research & Development, University of Porto Medical School, Porto, Portugal
| | - André Gomes
- Department of Internal Medicine, Hospital S. João, Porto, Portugal
| | - Ana Azevedo
- Department of Internal Medicine, Hospital S. João, Porto, Portugal; Unit of Cardiovascular Research & Development, University of Porto Medical School, Porto, Portugal; Department of Hygiene and Epidemiology, University of Porto Medical School, Porto, Portugal
| | - Francisco Rocha-Gonçalves
- Department of Cardiology, Hospital S. João, Porto, Portugal; Unit of Cardiovascular Research & Development, University of Porto Medical School, Porto, Portugal
| | - Paulo Bettencourt
- Department of Internal Medicine, Hospital S. João, Porto, Portugal; Unit of Cardiovascular Research & Development, University of Porto Medical School, Porto, Portugal
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211
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Shin JT, Dec GW. Ultrafiltration should not replace diuretics for the initial treatment of acute decompensated heart failure. Circ Heart Fail 2009; 2:505-11. [PMID: 19808382 PMCID: PMC2778229 DOI: 10.1161/circheartfailure.109.862474] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Affiliation(s)
- Jordan T Shin
- Heart Failure and Transplantation Unit, Cardiology Division, Massachusetts General Hospital Heart Center, Bigelow 800, 55 Fruit St, Boston, MA 02114, USA.
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Abstract
This article addresses a question that the authors consider to be somewhat rhetorical: are hemodynamic parameters predictors of mortality? It reviews the specific hemodynamic abnormalities and pathophysiologic consequences distinctive to the patient who has decompensation and addresses the data that implicate abnormal hemodynamics as a treatment target associated with increased mortality. The focus is on patients who have decompensated heart failure, defined as left ventricular systolic dysfunction and an acute, subacute, or gradual worsening of symptoms while receiving optimal medical therapy.
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213
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Vader JM, Drazner MH. Clinical assessment of heart failure: utility of symptoms, signs, and daily weights. Heart Fail Clin 2009; 5:149-60. [PMID: 19249684 DOI: 10.1016/j.hfc.2008.11.001] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
Heart failure is a clinical syndrome defined by the presence of characteristic signs and symptoms. History taking and physical examination have particular utility in assessing patients who have heart failure. In recent years the validity of conventional signs and symptoms of heart failure has been tested in large population studies and in clinical trials, providing an evidence basis for their utility in the clinical assessment of the patient who has known or suspected heart failure. There also has been progress in characterizing the process of acute decompensation from a previously chronic stable state. This article addresses the usefulness of signs and symptoms and daily weights in the assessment and management of patients who have heart failure.
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Affiliation(s)
- Justin M Vader
- University of Texas Southwestern Medical Center, Dallas, TX 75390-9047, USA
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214
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Thorsgard M, Bart BA. Ultrafiltration for congestive heart failure. CONGESTIVE HEART FAILURE (GREENWICH, CONN.) 2009; 15:136-43. [PMID: 19522963 DOI: 10.1111/j.1751-7133.2009.00054.x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Relief of congestive symptoms is a primary goal in treating heart failure. Ultrafiltration is a tool that can be used to safely remove sodium and water from whole blood at a controlled rate. Ultrafiltration decreases symptoms, relieves congestion, and improves hemodynamics, neurohormonal balance, and exercise capacity. This article describes the importance of congestion as a therapeutic target in heart failure and outlines the development of ultrafiltration as a treatment to address this important physiologic state.
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Affiliation(s)
- Marit Thorsgard
- Department of Medicine, Hennepin County Medical Center, Minneapolis, MN 55415, USA
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215
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A New Monitoring Method for the Estimation of Body Fluid Status by Digital Weight Scale Incorporating Bioelectrical Impedance Analyzer in Definite Heart Failure Patients. J Card Fail 2009; 15:410-8. [DOI: 10.1016/j.cardfail.2008.12.008] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2008] [Revised: 11/10/2008] [Accepted: 12/12/2008] [Indexed: 11/21/2022]
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216
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Shah SJ, Blair JEA, Filippatos GS, Macarie C, Ruzyllo W, Korewicki J, Bubenek-Turconi SI, Ceracchi M, Bianchetti M, Carminati P, Kremastinos D, Grzybowski J, Valentini G, Sabbah HN, Gheorghiade M. Effects of istaroxime on diastolic stiffness in acute heart failure syndromes: results from the Hemodynamic, Echocardiographic, and Neurohormonal Effects of Istaroxime, a Novel Intravenous Inotropic and Lusitropic Agent: a Randomized Controlled Trial in Patients Hospitalized with Heart Failure (HORIZON-HF) trial. Am Heart J 2009; 157:1035-41. [PMID: 19464414 DOI: 10.1016/j.ahj.2009.03.007] [Citation(s) in RCA: 97] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/11/2009] [Accepted: 03/05/2009] [Indexed: 11/30/2022]
Abstract
BACKGROUND Istaroxime is a novel intravenous agent with inotropic and lusitropic properties related to inhibition of the Na+/K+ adenosine triphosphatase and stimulation of sarcoplasmic reticulum calcium adenosine triphosphatase activity. We analyzed data from HORIZON-HF, a randomized, controlled trial evaluating the short-term effects of istaroxime in patients hospitalized with heart failure and left ventricular ejection fraction < or = 35% to test the hypothesis that istaroxime improves diastolic stiffness in acute heart failure syndrome. METHODS One hundred twenty patients were randomized 3:1 (istaroxime/placebo) to a continuous 6-hour infusion of 1 of 3 doses of istaroxime or placebo. All patients underwent pulmonary artery catheterization and comprehensive 2-dimensional/Doppler and tissue Doppler echocardiography at baseline and at the end of the 6-hour infusion. We quantified diastolic stiffness using pressure-volume analysis and tissue Doppler imaging of the lateral mitral annulus (E'). RESULTS Baseline characteristics were similar among all groups, with mean age 55 +/- 11 years, 88% men, left ventricular ejection fraction 27% +/- 7%, systolic blood pressure (SBP) 116 +/- 13 mm Hg, and pulmonary capillary wedge pressure (PCWP) 25 +/- 5 mm Hg. Istaroxime administration resulted in an increase in E' velocities, whereas there was a decrease in E' in the placebo group (P = .048 between groups). On pressure-volume analysis, istaroxime decreased end-diastolic elastance (P = .0001). On multivariate analysis, increasing doses of istaroxime increased E' velocity (P = .043) and E-wave deceleration time (P = .001), and decreased E/E' ratio (P = .047), after controlling for age, sex, baseline ejection fraction, change in PCWP, and change in SBP. CONCLUSIONS Istaroxime decreases PCWP, increases SBP, and decreases diastolic stiffness in patients with acute heart failure syndrome.
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Affiliation(s)
- Sanjiv J Shah
- Northwestern University Feinberg School of Medicine, Chicago, IL 60611, USA.
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217
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Tang WHW, Tong W. Measuring impedance in congestive heart failure: current options and clinical applications. Am Heart J 2009; 157:402-11. [PMID: 19249408 PMCID: PMC3058607 DOI: 10.1016/j.ahj.2008.10.016] [Citation(s) in RCA: 71] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/30/2008] [Accepted: 10/07/2008] [Indexed: 02/07/2023]
Abstract
Measurement of impedance is becoming increasingly available in the clinical setting as a tool for assessing hemodynamics and volume status in patients with heart failure. The 2 major categories of impedance assessment are the band electrode method and the implanted device lead method. The exact sources of the impedance signal are complex and can be influenced by physiologic effects such as blood volume, fluid, and positioning. This article provides a critical review of our current understanding and promises of impedance measurements, the techniques that have evolved, as well as the evidence and limitations regarding their clinical applications in the setting of heart failure management.
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Affiliation(s)
- W H Wilson Tang
- Heart and Vascular Institute, Cleveland Clinic, OH 44195, USA.
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218
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Collins SP, Levy PD, Lindsell CJ, Pang PS, Storrow AB, Miller CD, Naftilan AJ, Thohan V, Abraham WT, Hiestand B, Filippatos G, Diercks DB, Hollander J, Nowak R, Peacock WF, Gheorghiade M. The rationale for an acute heart failure syndromes clinical trials network. J Card Fail 2009; 15:467-74. [PMID: 19643356 DOI: 10.1016/j.cardfail.2008.12.013] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2007] [Revised: 10/21/2008] [Accepted: 12/22/2008] [Indexed: 01/08/2023]
Abstract
BACKGROUND Clinical trials involving novel therapies treating acute heart failure syndromes (AHFS) have shown limited success with regard to both efficacy and safety. As a direct result, outcomes have changed little over time and AHFS remains a disease process associated with largely no change in hospitalization rates (80%), hospital length of stay (median 4.5 days), and in-hospital (4-7%) and 60-day mortality (10%). Despite extensive emergency department (ED) involvement during the initial phase of AHFS management, clinical trials have enrolled patients after the ED phase of management, up to 48 hours after initial therapy, long after many patients have experienced significant beneficial effects of standard therapy. As standard therapy has provided symptomatic improvement in up to 70% of patients in these trials, it is not surprising that investigational agents started after 24 to 48 hours of standard therapy have shown limited clinical efficacy when compared with standard therapy. METHODS AND RESULTS The ability to screen, enroll, and randomize in the emergency setting is fundamental. The unique environment, the ethical complexities of enrollment in emergency-based research, and the need for rapid and standardized study-compliant care represent key challenges to active recruitment in AHFS studies. Specifically, the ability to identify and enroll a large cohort of AHFS patients early (<6 hours) in their presentation has been cited as the primary barrier to the appropriate design of clinical trials that includes this early window. CONCLUSIONS In response, we have created a network of dedicated academic physicians with experience in clinical trials and acute management of heart failure who together can surmount this barrier and provide a framework for conducting early trials in AHFS.
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Affiliation(s)
- Sean P Collins
- University of Cincinnati, Cincinnati, OH 45267-0769, USA
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Hernandez AF, O'Connor CM, Starling RC, Reist CJ, Armstrong PW, Dickstein K, Lorenz TJ, Gibler WB, Hasselblad V, Komajda M, Massie B, McMurray JJV, Nieminen M, Rouleau JL, Swedberg K, Califf RM. Rationale and design of the Acute Study of Clinical Effectiveness of Nesiritide in Decompensated Heart Failure Trial (ASCEND-HF). Am Heart J 2009; 157:271-7. [PMID: 19185633 DOI: 10.1016/j.ahj.2008.07.031] [Citation(s) in RCA: 123] [Impact Index Per Article: 8.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/13/2008] [Accepted: 07/24/2008] [Indexed: 12/01/2022]
Abstract
BACKGROUND Acute decompensated heart failure (ADHF) is a major public health burden with significant mortality and morbidity. Nesiritide is a recombinantly produced intravenous formulation of human B-type natriuretic peptide that promotes vasodilation and increases salt and water excretion, which results in reduced cardiac filling pressures. Prior studies have shown that dyspnea is improved in patients with ADHF 3 hours after nesiritide infusion with significant dose-related reductions in cardiac filling pressures and systemic vascular resistance without significant arrhythmias. However, the effect of nesiritide on dyspnea at 6 or 24 hours is unknown, and no clinical outcome trials have been done to provide a reliable estimate of the effect of nesiritide on morbidity and mortality. METHODS The Acute Study of Clinical Effectiveness of Nesiritide in Decompensated Heart Failure trial (ASCEND-HF) is a phase III study evaluating the efficacy and safety of nesiritide in patients with ADHF. Patients hospitalized for hear failure will be randomly assigned to receive either intravenous nesiritide or matching placebo for 24 hours to 7 days. The 2 coprimary end points are (1) assessment of acute dyspnea at 6 or 24 hours and (2) death or rehospitalization for hear failure within 30 days. A total of 7,000 patients will be enrolled worldwide between 2007 and 2010. CONCLUSIONS The data from the ASCEND-HF trial will establish whether nesiritide safely improves acute dyspnea as well as morbidity and mortality at 30 days.
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Affiliation(s)
- Adrian F Hernandez
- Duke Clinical Research Institute, Duke University Medical Center, Durham, NC, USA.
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220
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Gheorghiade M, Pang PS. Acute Heart Failure Syndromes. J Am Coll Cardiol 2009; 53:557-573. [PMID: 19215829 DOI: 10.1016/j.jacc.2008.10.041] [Citation(s) in RCA: 403] [Impact Index Per Article: 26.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/02/2008] [Revised: 10/21/2008] [Accepted: 10/26/2008] [Indexed: 01/08/2023]
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221
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Zhang H, Liu C, Ji Z, Liu G, Zhao Q, Ao YG, Wang L, Deng B, Zhen Y, Tian L, Ji L, Liu K. Prednisone adding to usual care treatment for refractory decompensated congestive heart failure. Int Heart J 2008; 49:587-95. [PMID: 18971570 DOI: 10.1536/ihj.49.587] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
The aim of the present study was to determine if prednisone, a glucocorticoid, added to conventional treatment for patients with decompensated congestive heart failure (DCHF) refractory to the conventional care, results in significant relief of congestive symptoms and improvement of clinical status. Diuretic-based strategies, as the mainstay in DCHF management, are not always effective in eliciting diuresis. However, the addition of prednisone to standard care may induce potent diuresis in this clinical setting. Thirty-five patients with DCHF were enrolled in the study, and prednisone (1 mg/kg/day with maximum dosage of 60 mg/day) was added to the standard treatment. Primary endpoints were the effects on daily urine volume, patient and physician assessed dyspnea and global clinical status, and changes in renal function. The addition of prednisone induced potent diuresis with time. As a result of the diuresis, congestive symptoms improved markedly in 80% and global clinical status improved markedly in 68.6% of the DCHF patients at the end of the study (P < 0.001). The change in serum creatinine from baseline was -12.21 micromol/L (P < 0.05). Adding prednisone to conventional care in the patients with refractory DCHF induced potent diuresis accompanied by a dramatic relief of congestive symptoms and improvements in clinical status and renal function.
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Affiliation(s)
- Huimin Zhang
- Cardiology Department, Hebei Medical University, Hebei, China
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222
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Haas GJ, Pestritto VM, Abraham WT. Ultrafiltration for Volume Control in Decompensated Heart Failure. Heart Fail Clin 2008; 4:519-34. [DOI: 10.1016/j.hfc.2008.03.004] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
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223
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Prognostic value of N-terminal pro-type-B natriuretic peptide and Doppler left ventricular diastolic variables in patients with chronic systolic heart failure stabilized by therapy. Am J Cardiol 2008; 102:463-8. [PMID: 18678307 DOI: 10.1016/j.amjcard.2008.03.083] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/07/2008] [Revised: 03/29/2008] [Accepted: 03/29/2008] [Indexed: 11/23/2022]
Abstract
Prognostication of patients with chronic heart failure (HF) stabilized by therapy may be difficult. Therefore, the aim was to evaluate whether combined assessment of plasma N-terminal pro-B natriuretic peptide (NT-pro-BNP) and Doppler left ventricular (LV) diastolic variables was relevant to the prognosis of patients with stable HF. Outpatients with LV systolic HF (ejection fraction < or =45%), classified using clinical criteria as decompensated (n = 94) and stable HF (n = 219), underwent a complete Doppler echocardiographic study. NT-pro-BNP was measured together with mitral wave velocities, E wave deceleration time, and tissue Doppler early septal annular velocity. Median follow-up was 22 months. Freedom from all-cause mortality or HF hospitalization at 24 months was worst (44%) in patients with decompensated HF, intermediate (58%) in patients with stable HF with NT-pro-BNP higher than the median (>1,129 pg/ml), and best (92%) in patients with lower NT-pro-BNP (log-rank p <0.0001). In patients with stable HF, NT-pro-BNP >1,129 pg/ml (hazard ratio [HR] 2.84, p = 0.003), E wave deceleration time <150 ms (HR 2.31, p = 0.004), and tissue Doppler early septal annular velocity <8 cm/s (HR 2.18, p = 0.01) were predictors of the end point at multivariate analysis. The addition of Doppler LV diastolic variables and NT-pro-BNP significantly improved the chi-square test for outcome prediction (from 14.4 to 46.4). In conclusion, NT-pro-BNP and spectral and tissue Doppler variables of LV diastolic dysfunction added independent and incremental contributions to prognostic stratification of patients with stable HF.
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224
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Parrinello G, Torres D, Paterna S, di Pasquale P, Licata G. The pathophysiology of acute heart failure: the key role of fluid accumulation. Am Heart J 2008; 156:e19. [PMID: 18657644 DOI: 10.1016/j.ahj.2008.04.031] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/18/2008] [Accepted: 04/30/2008] [Indexed: 11/29/2022]
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225
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Mariotti R, Borelli G, Coceani M, Zingaro S, Barison A, Morelli I, Rondinini L. Aldosterone receptor antagonism and heart failure: insights from an outpatient clinic. J Clin Pharm Ther 2008; 33:349-56. [PMID: 18613852 DOI: 10.1111/j.1365-2710.2008.00922.x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
OBJECTIVE In randomized clinical trials, aldosterone antagonists have been shown to reduce mortality and morbidity in heart failure (HF). The aim of the present study was to examine the risk-benefit profile of aldosterone antagonists in routine clinical practice. METHODS A retrospective analysis, extending over a 1-year period, of the clinical, instrumental and laboratory data of 264 HF outpatients was performed. All patients were on a beta-blocker and an ACE-inhibitor (or angiotensin-II receptor-blocker) and 151 were taking an aldosterone antagonist. RESULTS At baseline, subjects treated with aldosterone antagonists had a higher NYHA class, a larger left-ventricular end-diastolic volume, a worse ejection fraction and a higher systolic pulmonary arterial pressure (sPAP). During follow-up, a greater reduction in sPAP and a tendency towards improved systolic and diastolic function were observed in subjects treated with aldosterone antagonists. Moreover, clinical and laboratory parameters did not deteriorate in patients taking aldosterone antagonists. Mortality rates were similar in the two groups (8.6% vs. 8.8%, P = NS). CONCLUSIONS The use of aldosterone antagonists in HF is associated with an improvement in cardiac function and is well tolerated. In the present study, patients administered these agents had a comparable clinical outcome to that of the control group, despite important differences in baseline risk.
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Affiliation(s)
- R Mariotti
- Heart Failure Unit, Department of Cardiothoracic, University of Pisa, Pisa, Italy
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226
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Tang WHW, Van Lente F, Shrestha K, Troughton RW, Francis GS, Tong W, Martin MG, Borowski AG, Jasper S, Starling RC, Klein AL. Impact of myocardial function on cystatin C measurements in chronic systolic heart failure. J Card Fail 2008; 14:394-9. [PMID: 18514931 DOI: 10.1016/j.cardfail.2008.01.006] [Citation(s) in RCA: 48] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2007] [Revised: 11/21/2007] [Accepted: 01/11/2008] [Indexed: 11/27/2022]
Abstract
BACKGROUND The influence of myocardial function on plasma levels of cystatin C (CysC), a sensitive marker of renal function, in chronic systolic heart failure (HF) has not been well established. METHODS We prospectively identified 139 subjects with stable, chronic HF (left ventricular ejection fraction < or = 35%) and measured plasma levels of CysC. We prospectively tracked patients' long-term adverse clinical outcomes (death, cardiac transplantation, and HF hospitalizations). RESULTS Plasma levels of CysC were elevated in 41% of patients with preserved renal function and directly correlated with N-terminal prohormone brain natriuretic peptide (r = 0.57, P < .0001). There was a significant association between CysC and mitral E/septal E' ratio (r = 0.34, P < .001), right ventricular systolic dysfunction severity (r = 0.30, P < .001), and mitral regurgitation severity (r = 0.31, P < .001), but not left ventricular ejection fraction. At the cutoff of 1.23 mg/dL, CysC remains a significant independent risk factor for adverse clinical outcomes (hazard ratio 1.88, 95% confidence interval 1.15-3.09, P = .012) after adjusting for estimated glomerular filtration rate, left ventricular ejection fraction, and E/septal E'. CONCLUSION CysC is associated with more advanced left ventricular diastolic dysfunction and right ventricular systolic dysfunction and remains an independent predictor of long-term prognosis in chronic systolic HF after adjusting for myocardial factors.
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Affiliation(s)
- W H Wilson Tang
- Kaufman Center for Heart Failure, Department of Cardiovascular Medicine, Cleveland Clinic, Cleveland Ohio 44195, USA
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Petrie CJ, Mark PB, Weir RAP. Broken pump or leaky filter? Renal dysfunction in heart failure a contemporary review. Int J Cardiol 2008; 128:154-65. [PMID: 18191240 DOI: 10.1016/j.ijcard.2007.12.016] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/13/2007] [Revised: 08/17/2007] [Accepted: 12/11/2007] [Indexed: 11/20/2022]
Abstract
Renal dysfunction is a frequent and progressive complication of chronic heart failure and is a powerful predictor of cardiovascular mortality. It is intimately associated with cardiovascular disease even in its earliest stages. Although cardiovascular and renal disease share many risk factors, the prognostic implications do not simply reflect widespread atherosclerotic vascular disease as this appears to be as important in those with heart failure secondary to idiopathic dilated cardiomyopathy as it is in those with coronary artery disease. There may be a role in the progression of heart failure, as the deleterious effects of even "mild" renal impairment seem to be borne out in predicting outcome, in a broad range of heart failure patients including those with heart failure and preserved systolic function. Renal dysfunction is both an indication for, as well as frequently limiting intervention with intensive disease modifying therapy. Although renal impairment is common in heart failure and these patients are at higher risk for adverse events including death, they are under represented in clinical trials.
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Affiliation(s)
- Colin J Petrie
- Department of Cardiology, Western Infirmary, Glasgow, United Kingdom.
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229
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Virani SA. Management of Acute Decompensated Heart Failure: Renal Implications. Blood Purif 2008; 26:18-22. [DOI: 10.1159/000110558] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
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230
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Metra M, Dei Cas L, Bristow MR. The pathophysiology of acute heart failure--it is a lot about fluid accumulation. Am Heart J 2008; 155:1-5. [PMID: 18082481 DOI: 10.1016/j.ahj.2007.10.011] [Citation(s) in RCA: 42] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/08/2007] [Accepted: 10/08/2007] [Indexed: 11/16/2022]
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231
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Sayers SL, Riegel B, Goldberg LR, Coyne JC, Samaha FF. Clinical exacerbations as a surrogate end point in heart failure research. Heart Lung 2008; 37:28-35. [DOI: 10.1016/j.hrtlng.2007.02.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2006] [Revised: 02/06/2007] [Accepted: 02/12/2007] [Indexed: 10/22/2022]
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232
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Albert NM, Buchsbaum R, Li J. Randomized study of the effect of video education on heart failure healthcare utilization, symptoms, and self-care behaviors. PATIENT EDUCATION AND COUNSELING 2007; 69:129-39. [PMID: 17913440 DOI: 10.1016/j.pec.2007.08.007] [Citation(s) in RCA: 76] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/21/2006] [Revised: 05/15/2007] [Accepted: 08/20/2007] [Indexed: 05/17/2023]
Abstract
OBJECTIVE Adherence to self-care behaviors improves heart failure (HF) morbidity and life quality. We examined short-term impact of video education (VE) in addition to standard education (SE) on HF healthcare utilization and self-care behavior adherence. METHODS One hundred and twelve hospitalized patients were randomly assigned to SE (n=53) or SE plus VE (n=59). Differences between groups were analyzed in patients who underwent 3-month follow-up (39 SE and 37 VE patients). Mean age was 60+/-14 years; mean HF length was 57 months. RESULTS Three-month healthcare utilization was similar between groups but VE patients needed less extra diuretic dosing (P<0.02), received more HF literature (P<0.03), and had less healthcare team telephone communication (P<0.04). VE patients had greater sign/symptom reduction (P<0.04); especially related to edema (P<0.01) and fatigue (P<0.01) and initiated more actions for edema (P<0.05) and dyspnea (with exercise or rest, both P<0.01). Overall, VE patients had a higher mean self-care behavior score (P<0.01), reflecting greater self-care adherence. CONCLUSION Video education prompts self-care behavior adherence to control worsening signs/symptoms of volume overload. During 3-month follow-up, utilization of most healthcare resources was unchanged. PRACTICE IMPLICATIONS VE is a useful adjunct to in-person education.
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Affiliation(s)
- Nancy M Albert
- Division of Nursing and George M. and Linda H. Kaufman, Center for Heart Failure, The Cleveland Clinic Foundation, Cleveland, USA.
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233
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Shoaf SE, Bramer SL, Bricmont P, Zimmer CA. Pharmacokinetic and pharmacodynamic interaction between tolvaptan, a non-peptide AVP antagonist, and furosemide or hydrochlorothiazide. J Cardiovasc Pharmacol 2007; 50:213-22. [PMID: 17703139 DOI: 10.1097/fjc.0b013e318074f934] [Citation(s) in RCA: 48] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
The pharmacokinetic and pharmacodynamic interactions between tolvaptan and furosemide or hydrochlorothiazide (HCTZ) were determined in a single-center, randomized, open-label, parallel-arm, 3-period crossover study conducted in healthy white (Caucasian) men. A total of 12 subjects were enrolled in the study, with 6 subjects assigned to each of two treatment arms. Subjects in Arm 1 received 30 mg of tolvaptan, 80 mg of furosemide, and 30 mg of tolvaptan + 80 mg of furosemide. Subjects in Arm 2 received 30 mg of tolvaptan, 100 mg of HCTZ, and 30 mg pf tolvaptan + 100 mg of HCTZ. Doses were separated by a 48-hour washout. Blood and urine samples were collected at scheduled timepoints during the 24 hours after administration of study drug for the determination of pharmacokinetic and pharmacodynamic parameters. No clinically significant changes were noted in the pharmacokinetic profiles of tolvaptan and furosemide or tolvaptan and HCTZ when coadministered. Free water clearance, 24-hour urine volume, plasma sodium and argentine vasopressin concentrations, and plasma osmolality were higher, and urine osmolality was lower when tolvaptan was administered either alone or in combination with furosemide or HCTZ, compared with furosemide or HCTZ administered alone. At 24 hours postdose, plasma renin activity was increased after furosemide or HCTZ administered alone or with tolvaptan, but it was unchanged after tolvaptan alone. Tolvaptan did not significantly affect the natriuretic activity of furosemide or HCTZ. Furosemide and HCTZ did not significantly affect the aquaretic activity of tolvaptan. Tolvaptan administered alone or in combination with furosemide or HCTZ was safe and well tolerated at the given doses.
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Affiliation(s)
- Susan E Shoaf
- Clinical Pharmacology, Otsuka Pharmaceutical Development & Commercialization, Inc., Rockville, MD 20850, USA.
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234
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Patel J, Smith M, Heywood JT. Optimal use of diuretics in patients with heart failure. CURRENT TREATMENT OPTIONS IN CARDIOVASCULAR MEDICINE 2007; 9:332-42. [PMID: 17761118 DOI: 10.1007/s11936-007-0028-z] [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: 10/23/2022]
Abstract
Currently, the use of diuretics in heart failure (HF) remains more of an art than a science. Diuretics are the principle means for relieving congestion in patients with decompensated HF. Unfortunately, they persist as the only major therapy in HF that has not been subjected to a large randomized clinical trial, precisely because no comparable therapy exists that can so easily, efficiently, and inexpensively treat fluid overload. Nonetheless, diuretics have many potential drawbacks, including electrolyte abnormalities, neurohormonal activation, hypovolemia, renal dysfunction, and direct myocardial effects. Until definitive answers about mortality are settled, the lowest dose of a diuretic that can produce euvolemia should be employed and these agents should be discontinued when possible. Many outpatients with HF can be managed quite well without diuretics once adequate neurohormonal blockade with angiotensin-converting enzyme inhibitors and beta blockers has been achieved.
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Affiliation(s)
- Jigar Patel
- Scripps Clinic, Department of Cardiology, Mailstop: SW206, 10666 North Torrey Pines Road, La Jolla, CA 92037, USA
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235
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Beck-da-Silva L, Rohde LE, Goldraich L, Clausell N. Clinical findings, natriuretic peptides, and echocardiography: integrating tools to optimize heart failure management. CONGESTIVE HEART FAILURE (GREENWICH, CONN.) 2007; 13:158-63. [PMID: 17541310 DOI: 10.1111/j.1527-5299.2007.06401.x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/15/2023]
Abstract
The hemodynamic profile of heart failure (HF) patients may be critical to their clinical outcome, whereby congestion emerges as a particularly important aspect to define therapeutic goals, optimize HF treatment, and determine prognosis. Accordingly, individualized HF management must include several strategies to detect congestion, which might easily be underestimated in chronic HF patients. Therefore, it is important to recognize the true reliability of traditional HF signs and symptoms. The contemporary understanding of HF has brought new value to some aspects of physical examination. Natriuretic peptides have emerged as potential new tools in the diagnosis of congestion in patients with HF, and echocardiography has gained renewed importance in HF management when it is used to investigate hemodynamic profile. The aim of this article is to review and integrate these 3 ways of assessing and monitoring HF patients: clinical findings, natriuretic peptides, and echocardiography.
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Affiliation(s)
- Luis Beck-da-Silva
- Heart Failure and Transplant Unit of Cardiovascular Division, Hospital de Clínicas de Porto Alegre, Porto Alegre, RS, Brazil
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236
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Abstract
Electrical devices, Cardiac Resynchronization Therapy (CRT) pacemakers, the Implantable Cardiac Defibrillator (ICD) and a combination of both, constitute an important line of treatment in the therapy of moderate to severe chronic heart failure. The effectiveness of these devices in the treatment of acute decompensated heart failure has yet to be systematically evaluated. However, the beneficial clinical effects of CRT translate into a marked reduction of heart failure-related hospitalization. Devices also offer unique diagnostic applications by continuous measurement of clinically useful physiological parameters over time. Of particular interest, monitoring of intrathoracic impedance and right ventricular pressures allows to detect changes in volume load in an early stage prior to the development of clinical symptoms. This information could be helpful to stop further progression to acute cardiac decompensation and to avoid hospitalization and acute clinical events. Using modern telecommunication technology, patients can also be remotely monitored in their daily living environment. In consequence, the incorporation of device technology into heart failure management programs calls for a close cooperation between heart failure specialists and electrophysiologists. This review addresses therapeutic and diagnostic aspects of device therapies in the context of acute heart failure.
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Affiliation(s)
- Frieder Braunschweig
- Department of Cardiology, Karolinska University Hospital, 171 76, Stockholm, Sweden.
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237
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Elkayam U, Hatamizadeh P, Janmohamed M. The challenge of correcting volume overload in hospitalized patients with decompensated heart failure. J Am Coll Cardiol 2007; 49:684-6. [PMID: 17291933 DOI: 10.1016/j.jacc.2006.10.051] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/11/2006] [Accepted: 10/17/2006] [Indexed: 10/23/2022]
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238
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Gheorghiade M, Filippatos G, De Luca L, Burnett J. Congestion in acute heart failure syndromes: an essential target of evaluation and treatment. Am J Med 2006; 119:S3-S10. [PMID: 17113398 DOI: 10.1016/j.amjmed.2006.09.011] [Citation(s) in RCA: 298] [Impact Index Per Article: 16.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
Abstract
Patients with acute heart failure syndromes (AHFS) typically present with signs and symptoms of systemic and pulmonary congestion at admission. However, elevated left ventricular (LV) filling pressures (hemodynamic congestion) may be present days or weeks before systemic and pulmonary congestion develop, resulting in hospital admission. This "hemodynamic congestion," with or without clinical congestion, may have deleterious effects including subendocardial ischemia, alterations in LV geometry resulting in secondary mitral insufficiency, and impaired cardiac venous drainage from coronary veins resulting in diastolic dysfunction. It is possible that these hemodynamic abnormalities in addition to neurohormonal activation may contribute to LV remodeling and heart failure progression. Approximately 50% of patients admitted for AHFS are discharged with persistent symptoms and/or minimal or no weight loss in spite of the fact that the main reason for admission was clinical congestion. Accordingly, the assessment and management of pulmonary and systemic congestion in these patients require reevaluation.
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Affiliation(s)
- Mihai Gheorghiade
- Division of Cardiology, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA.
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239
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Abstract
The inability to effectively regulate volume status is a major consequence of acute heart failure syndromes (AHFS). A variety of pathophysiologic processes contribute to this impairment, most notably neurohormonal activation of the renin-angiotensin-aldosterone system, arginine vasopressin, and the sympathetic nervous system. As a result, addressing volume overload is one of the most challenging aspects of AHFS management. Neurohormonal activation leads to substantial changes in hemodynamics and myocardial remodeling, which further contribute to the severity of heart failure (HF) disease and thereby cyclically increase the risk of further neurohormonal activation. Pulmonary capillary wedge pressure is a dependable reflection of volume status and has been used as a surrogate marker in recent studies to assess disease progression in response to innovative HF treatment strategies. Future approaches to HF treatment should focus on the more accurate assessment and management of volume status in an effort to improve patient care.
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Affiliation(s)
- Horng H Chen
- Division of Cardiovascular Diseases, Department of Internal Medicine, Mayo Clinic and Foundation, Rochester, Minnesota, USA.
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240
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Albert NM. Bioimpedance cardiography measurements of cardiac output and other cardiovascular parameters. Crit Care Nurs Clin North Am 2006; 18:195-202, x. [PMID: 16728305 DOI: 10.1016/j.ccell.2006.01.008] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
This paper describes impedance technique and device types, discusses hemodynamic data parameters that are available, discusses the differences between impedance cardiography and data that are derived from invasive pulmonary artery catheters, and explains how nurses can apply bioimpedance cardiography in a variety of patient populations.
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Affiliation(s)
- Nancy M Albert
- Cleveland Clinic, 9500 Euclid Avenue, P-32, Cleveland, OH 44195, USA.
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241
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Lewis EF, Hellkamp AS, Pfeffer MA, Greenspon AJ, Machado C, Singh S, Schron E, Lee KL, Lamas GA. The association of the heart failure score with mortality and heart failure hospitalizations in elderly patients: insights from the Mode Selection Trial (MOST). Am Heart J 2006; 151:699-705. [PMID: 16504635 DOI: 10.1016/j.ahj.2005.05.018] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/26/2004] [Accepted: 05/02/2005] [Indexed: 11/20/2022]
Abstract
BACKGROUND Patient and physician preferences as well as cost favor an increasingly higher threshold for hospital admission for heart failure (HF) treatment. This trend risks masking the severity and prevalence of HF as hospitalization for HF may decrease. METHODS Heart Failure Score (HFS) has 4 ordinal subscales assessing (1) HF symptoms, physical signs of left (2) and (3) right HF, and (4) therapy changes for HF. Heart Failure Score was calculated for 1257 of 2010 (63%) patients enrolled in the MOST trial in sinus node dysfunction, who survived and had complete first-year HFS data at 4 postpacemaker implant visits (1, 3, 6, and 12 months). Heart Failure Score was summed and ranged from 0 to 14, with lower scores representing less HF. RESULTS There were 1257 patients (median age 74 years [interquartile range 68-79], 47% were women, 61% had hypertension, 20%, diabetes mellitus, and 23%, prior myocardial infarction). The median HFS accumulated during 1 year was 4 (interquartile range 1-8). Of patients with a benign first year, those with a higher HFS were more likely to die during subsequent follow-up compared with patients with lower HFS (hazard ratio 1.07, 95% CI 1.04-1.10 for each 1-point increase, P < .001). CONCLUSIONS Increasing HFS is associated with an increased risk of mortality in mostly elderly patients without pre-existing HF. Heart Failure Score may be a useful surrogate HF end point for clinical trials.
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Affiliation(s)
- Eldrin F Lewis
- Cardiovascular Division, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA.
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De Luca L, Orlandi C, Udelson JE, Fedele F, Gheorghiade M. Overview of vasopressin receptor antagonists in heart failure resulting in hospitalization. Am J Cardiol 2005; 96:24L-33L. [PMID: 16399090 DOI: 10.1016/j.amjcard.2005.09.067] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
Patients with worsening heart failure (HF) requiring hospitalization commonly have a history of progressive fluid retention, decreased renal function, and hyponatremia. For these patients, diuretics have traditionally been the mainstay of treatment, but they are associated with electrolyte abnormalities and impaired renal function. Previous studies have shown that levels of the endogenous arginine vasopressin (AVP) hormone are elevated in patients with HF and may be the contributing factor to fluid retention and hyponatremia, and probably progression of HF. Vasopressin antagonists represent a unique class of therapeutic agents because of their potential role in both the short- and long-term treatment of patients hospitalized with worsening HF. As "aquaretics," AVP antagonists offer the possibility of added efficacy in relieving congestion and improving symptoms with minimal adverse effects in combination with standard medical therapy. Some AVP receptor antagonists have shown promising results in animal studies and small-scale clinical trials. The purpose of this review was to update the current status of studies with the available AVP antagonists.
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Affiliation(s)
- Leonardo De Luca
- Department of Cardiovascular and Respiratory Sciences, La Sapienza University, Rome, Italy
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244
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Shah MR, Claise KA, Bowers MT, Bhapkar M, Little J, Nohria A, Gaulden LH, McKee VK, Cozart KL, Mancinelli KL, Daniels H, Kinard T, Stevenson LW, Mancini DM, O'Connor CM, Califf RM. Testing new targets of therapy in advanced heart failure: the design and rationale of the Strategies for Tailoring Advanced Heart Failure Regimens in the Outpatient Setting: BRain NatrIuretic Peptide Versus the Clinical CongesTion ScorE (STARBRITE) trial. Am Heart J 2005; 150:893-8. [PMID: 16290955 DOI: 10.1016/j.ahj.2005.01.003] [Citation(s) in RCA: 39] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/07/2004] [Accepted: 01/06/2005] [Indexed: 02/07/2023]
Affiliation(s)
- Monica R Shah
- Center for Advanced Cardiac Care, Columbia University Medical Center, New York, NY 10032, USA.
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245
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Orlandi C, Zimmer CA, Gheorghiade M. Role of vasopressin antagonists in the management of acute decompensated heart failure. Curr Heart Fail Rep 2005; 2:131-9. [PMID: 16138949 DOI: 10.1007/s11897-005-0021-3] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Vasopressin antagonists are a class of neurohormonal antagonists with applications in both the short-term and long-term management of patients with acute decompensated heart failure (ADHF). The pharmacologic effects of vasopressin antagonists include changes in fluid balance and hemodynamics that may improve symptoms and outcomes in patients hospitalized with ADHF. With chronic therapy, vasopressin antagonists offer the potential to improve outcomes through a variety of mechanisms, including more effective treatment of congestion, preservation or improvement of renal function, or a reduction in the use of concomitant loop diuretic therapy. Several vasopressin antagonists are currently in advanced clinical trials for the treatment of ADHF, chronic stable heart failure, and hyponatremia.
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Affiliation(s)
- Cesare Orlandi
- Department of Clinical Development, Otsuka Maryland Research Institute, Inc., 2440 Research Boulevard, Rockville, MD 20850, USA.
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246
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Affiliation(s)
- Lynne Warner Stevenson
- Cardiovascular Division, Brigham and Women's Hospital, 75 Francis St, Boston, MA 02115, USA
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247
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Gheorghiade M, Orlandi C, Burnett JC, Demets D, Grinfeld L, Maggioni A, Swedberg K, Udelson JE, Zannad F, Zimmer C, Konstam MA. Rationale and Design of the Multicenter, Randomized, Double-Blind, Placebo-Controlled Study to Evaluate the Efficacy of Vasopressin Antagonism in Heart Failure: Outcome Study with Tolvaptan (EVEREST). J Card Fail 2005; 11:260-9. [PMID: 15880334 DOI: 10.1016/j.cardfail.2005.03.009] [Citation(s) in RCA: 142] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
BACKGROUND Hospitalizations for worsening heart failure due to fluid overload (congestion) are common. Agents that treat congestion without causing electrolyte abnormalities or worsening renal function are needed. Tolvaptan is an oral vasopressin (V 2 ) antagonist that decreases body weight and increases urine volume without inducing renal dysfunction or hypokalemia. The Efficacy of Vasopressin antagonism in Heart Failure Outcome Study with Tolvaptan (EVEREST) trial is evaluating mortality, morbidity, and patient-assessed global clinical status in patients treated with tolvaptan compared with standard care. METHODS AND RESULTS Patients are eligible for inclusion if they have a reduced left ventricular ejection fraction and are hospitalized for worsening heart failure with evidence of systemic congestion. Patients are randomized 1:1 to tolvaptan 30 mg/day or matching placebo for a minimum of 60 days. Time to all-cause mortality and time to cardiovascular mortality or heart failure hospitalization are the coprimary end points. Patient-assessed global clinical status and quality of life are also evaluated. EVEREST will be continued until 1065 deaths occur. As of April 18, 2005, 2260 patients have been enrolled. CONCLUSION Tolvaptan has been shown to reduce body weight in patients with worsening heart failure without inducing renal dysfunction or causing hypokalemia. The results of EVEREST will determine whether these effects translate into improved clinical outcomes.
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Affiliation(s)
- Mihai Gheorghiade
- Division of Cardiology, Northwestern Feinberg School of Medicine, Chicago, IL, USA
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248
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Sackner-Bernstein JD. Management of diuretic-refractory, volume-overloaded patients with acutely decompensated heart failure. Curr Cardiol Rep 2005; 7:204-10. [PMID: 15865862 DOI: 10.1007/s11886-005-0078-3] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
Fluid overload is a common presentation for decompensated heart failure, yet management strategies are poorly defined because of relatively few randomized clinical trials that delineate an optimal strategy. Patients refractory to diuretic therapy may be considered for treatment with inotropes or vasodilators, and others may be considered for venovenous ultrafiltration. The rationale for use of each therapy is reviewed.
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Affiliation(s)
- Jonathan D Sackner-Bernstein
- Clinical Scholars Program, Division of Cardiology, 1st Floor Cohen, North Shore University Hospital, 300 Community Drive, Manhasset, NY 11030, USA.
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249
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Stevenson LW. Design of therapy for advanced heart failure. Eur J Heart Fail 2005; 7:323-31. [PMID: 15718172 DOI: 10.1016/j.ejheart.2005.01.004] [Citation(s) in RCA: 40] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/04/2004] [Revised: 10/26/2004] [Accepted: 01/10/2005] [Indexed: 11/27/2022] Open
Abstract
Advanced heart failure has been defined as persistent symptoms (NYHA class III-IV) that limit daily life despite routine therapy with agents of known benefit. Although these symptoms can occur both with low and preserved ejection fraction, the majority of reported experience is with low ejection fraction, usually <25%. For this population with expected one year mortality of 30-50%, over twice the mortality of the landmark trials of medical therapy, there is little trial data to guide management, which is based largely on collected experience. Once the disease has progressed to this stage, therapy focuses upon the twin goals of symptom relief and prolongation of survival and is guided according to the hemodynamic profiles defined by clinical assessment. As symptoms at this stage relate largely to the congestion, therapy is targeted to reduction of elevated pulmonary venous and/or systemic venous pressures to near normal levels. The most common obstacle to relief of congestion is the increasingly recognized cardio-renal syndrome, for which both understanding and therapy are currently limited. Design of the outpatient regimen for advanced heart failure must be tailored to the individual patient. Many patients with advanced heart failure cannot tolerate "target" doses of neurohormonal antagonists, and spironolactone should be used only when clinical and renal function are sufficiently stable and frequently monitored in order to avoid life-threatening hyperkalemia. The clinical benefit of bi-ventricular pacing is substantial for the small proportion of patients likely to benefit. The vast majority of patients will never be eligible for cardiac transplantation or ventricular assist devices. To derive maximal benefit from all available therapies, heart failure disease management with collaboration of physicians and specialized nurses offers the greatest benefit to the greatest number of patients with advanced heart failure.
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Affiliation(s)
- Lynne Warner Stevenson
- Cardiovascular Division, Brigham and Women's Hospital, 75 Francis St., Boston, MA 02115, USA
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Uemura K, Kawada T, Kamiya A, Aiba T, Hidaka I, Sunagawa K, Sugimachi M. Prediction of circulatory equilibrium in response to changes in stressed blood volume. Am J Physiol Heart Circ Physiol 2005; 289:H301-7. [PMID: 15708956 DOI: 10.1152/ajpheart.01237.2004] [Citation(s) in RCA: 30] [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
Accurate prediction of cardiac output (CO), left atrial pressure (PLA), and right atrial pressure (PRA) is a prerequisite for management of patients with compromised hemodynamics. In our previous study (Uemura et al. Am J Physiol Heart Circ Physiol 286: H2376-H2385, 2004), we demonstrated a circulatory equilibrium framework, which permits the prediction of CO, PLA, and PRA once the venous return surface and integrated CO curve are known. Inasmuch as we also showed that the surface can be estimated from single-point CO, PLA, and PRA measurements, we hypothesized that a similar single-point estimation of the CO curve would enable us to predict hemodynamics. In seven dogs, we measured the PLA-CO and PRA-CO relations and derived a standardized CO curve using the logarithmic function CO = SL[ln(PLA - 2.03) + 0.80] for the left heart and CO = SR[ln(PRA - 2.13) + 1.90] for the right heart, where SL and SR represent the preload sensitivity of CO, i.e., pumping ability, of the left and right heart, respectively. To estimate the integrated CO curve in each animal, we calculated SL and SR from single-point CO, PLA, and PRA measurements. Estimated and measured CO agreed reasonably well. In another eight dogs, we altered stressed blood volume (-8 to +8 ml/kg of reference volume) under normal and heart failure conditions and predicted the hemodynamics by intersecting the surface and the CO curve thus estimated. We could predict CO [y = 0.93x + 6.5, r2 = 0.96, standard error of estimate (SEE) = 7.5 ml.min(-1).kg(-1)], PLA (y = 0.90x + 0.5, r2= 0.93, SEE = 1.4 mmHg), and PRA (y = 0.87x + 0.4, r2= 0.91, SEE = 0.4 mmHg) reasonably well. In conclusion, single-point estimation of the integrated CO curve enables accurate prediction of hemodynamics in response to extensive changes in stressed blood volume.
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Affiliation(s)
- Kazunori Uemura
- Dept. of Cardiovascular Dynamics, National Cardiovascular Center Research Institute, 5-7-1 Fujishirodai, Suita 565-8565, Japan.
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