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D’Amario D, Camilli M, Migliaro S, Canonico F, Galli M, Arcudi A, Montone RA, Borovac JA, Crea F, Savarese G. Sex-Related Differences in Dilated Cardiomyopathy with a Focus on Cardiac Dysfunction in Oncology. Curr Cardiol Rep 2020; 22:102. [PMID: 32770480 PMCID: PMC7413835 DOI: 10.1007/s11886-020-01377-z] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
PURPOSE OF REVIEW The aim of this report is to describe the main aspects of sex-related differences in non-ischemic dilated cardiomyopathies (DCM), focusing on chemotherapy-induced heart failure (HF) and investigating the possible therapeutic implications and clinical management applications in the era of personalized medicine. RECENT FINDINGS In cardio-oncology, molecular and multimodality imaging studies confirm that sex differences do exist, affecting the therapeutic cardioprotective strategies and, therefore, the long-term outcomes. Interestingly, compelling evidences suggest that sex-specific characteristics in drug toxicity might predict differences in the therapeutic response, most likely due to the tangled interplay between cancer and HF, which probably share common underlying mechanisms. Cardiovascular diseases show many sex-related differences in prevalence, etiology, phenotype expression, and outcomes. Complex molecular mechanisms underlie this diverse pathological manifestations, from sex-determined differential gene expression to sex hormone interaction with their receptors in the heart. Non-ischemic DCM is an umbrella definition that incorporates several etiologies, including chemotherapy-induced cardiomyopathies. The role of sex as a risk factor for cardiotoxicity is poorly explored. However, understanding the various features of disease manifestation and outcomes is of paramount importance for a prompt and tailored evaluation.
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Affiliation(s)
- Domenico D’Amario
- Dipartimento di Scienze Cardiovascolari, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - Massimiliano Camilli
- Dipartimento di Scienze Cardiovascolari, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Stefano Migliaro
- Dipartimento di Scienze Cardiovascolari, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Francesco Canonico
- Dipartimento di Scienze Cardiovascolari, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Mattia Galli
- Dipartimento di Scienze Cardiovascolari, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Alessandra Arcudi
- Dipartimento di Scienze Cardiovascolari, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Rocco Antonio Montone
- Dipartimento di Scienze Cardiovascolari, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | | | - Filippo Crea
- Dipartimento di Scienze Cardiovascolari, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
- Dipartimento di Scienze Cardiovascolari, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Gianluigi Savarese
- Cardiology Division, Department of Medicine, Karolinska Institutet, Stockholm, Sweden
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Prognostic value of hemodynamics and comorbidities in pulmonary hypertension due to advanced heart failure. Heart Lung 2020; 49:158-164. [DOI: 10.1016/j.hrtlng.2019.10.003] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2019] [Revised: 10/11/2019] [Accepted: 10/14/2019] [Indexed: 01/03/2023]
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Chen R, Lu A, Wang J, Ma X, Zhao L, Wu W, Du Z, Fei H, Lin Q, Yu Z, Liu H. Using machine learning to predict one-year cardiovascular events in patients with severe dilated cardiomyopathy. Eur J Radiol 2019; 117:178-183. [PMID: 31307645 DOI: 10.1016/j.ejrad.2019.06.004] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2018] [Revised: 06/06/2019] [Accepted: 06/08/2019] [Indexed: 12/23/2022]
Abstract
PURPOSE Dilated cardiomyopathy (DCM) is a common form of cardiomyopathy and it is associated with poor outcomes. A poor prognosis of DCM patients with low ejection fraction has been noted in the short-term follow-up. Machine learning (ML) could aid clinicians in risk stratification and patient management after considering the correlation between numerous features and the outcomes. The present study aimed to predict the 1-year cardiovascular events in patients with severe DCM using ML, and aid clinicians in risk stratification and patient management. MATERIALS AND METHODS The dataset used to establish the ML model was obtained from 98 patients with severe DCM (LVEF < 35%) from two centres. Totally 32 features from clinical data were input to the ML algorithm, and the significant features highly relevant to the cardiovascular events were selected by Information gain (IG). A naive Bayes classifier was built, and its predictive performance was evaluated using the area under the curve (AUC) of the receiver operating characteristics by 10-fold cross-validation. RESULTS During the 1-year follow-up, a total of 22 patients met the criterion of the study end-point. The top features with IG > 0.01 were selected for ML model, including left atrial size (IG = 0.240), QRS duration (IG = 0.200), and systolic blood pressure (IG = 0.151). ML performed well in predicting cardiovascular events in patients with severe DCM (AUC, 0.887 [95% confidence interval, 0.813-0.961]). CONCLUSIONS ML effectively predicted risk in patients with severe DCM in 1-year follow-up, and this may direct risk stratification and patient management in the future.
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Affiliation(s)
- Rui Chen
- Department of Radiology, Guangdong Provincial People's Hospital, Guangdong Academy of Medical Sciences, Guangzhou, Guangdong Province, China; School of Medicine, South China University of Technology, Guangzhou, Guangdong Province, China
| | - Aijia Lu
- Department of Radiology, Beijing Anzhen Hospital, Capital Medical University, Beijing, China
| | - Jingjing Wang
- Department of Radiology, Guangdong Provincial People's Hospital, Guangdong Academy of Medical Sciences, Guangzhou, Guangdong Province, China; School of Medicine, South China University of Technology, Guangzhou, Guangdong Province, China
| | - Xiaohai Ma
- Department of Radiology, Beijing Anzhen Hospital, Capital Medical University, Beijing, China
| | - Lei Zhao
- Department of Radiology, Beijing Anzhen Hospital, Capital Medical University, Beijing, China
| | - Wanjia Wu
- Department of Radiology, Guangdong Provincial People's Hospital, Guangdong Academy of Medical Sciences, Guangzhou, Guangdong Province, China
| | - Zhicheng Du
- Department of Medical Statistics and Epidemiology, Health Information Research Center, Guangdong Key Laboratory of Medicine, School of Public Health, Sun Yat-sen University, Guangzhou, Guangdong Province, China
| | - Hongwen Fei
- Department of Cardiology, Guangdong Provincial People's Hospital, Guangdong Academy of Medical Sciences, Guangzhou, Guangdong Province, China
| | - Qiongwen Lin
- Department of Cardiology, Guangdong Provincial People's Hospital, Guangdong Academy of Medical Sciences, Guangzhou, Guangdong Province, China
| | - Zhuliang Yu
- College of Automation Science and Engineering, South China University of Technology, Guangzhou, Guangdong Province, China.
| | - Hui Liu
- Department of Radiology, Guangdong Provincial People's Hospital, Guangdong Academy of Medical Sciences, Guangzhou, Guangdong Province, China; School of Medicine, South China University of Technology, Guangzhou, Guangdong Province, China.
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Orimoloye OA, Kambhampati S, Hicks AJ, Al Rifai M, Silverman MG, Whelton S, Qureshi W, Ehrman JK, Keteyian SJ, Brawner CA, Dardari Z, Al-Mallah MH, Blaha MJ. Higher cardiorespiratory fitness predicts long-term survival in patients with heart failure and preserved ejection fraction: the Henry Ford Exercise Testing (FIT) Project. Arch Med Sci 2019; 15:350-358. [PMID: 30899287 PMCID: PMC6425214 DOI: 10.5114/aoms.2019.83290] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/21/2018] [Accepted: 03/11/2018] [Indexed: 12/22/2022] Open
Abstract
INTRODUCTION Higher cardiorespiratory fitness (CRF) is associated with improved exercise capacity and quality of life in heart failure with preserved ejection fraction (HFpEF), but there are no large studies evaluating the association of HFpEF, CRF, and long-term survival. We therefore aimed to determine the association between CRF and all-cause mortality, in patients with HFpEF. MATERIAL AND METHODS In the Henry Ford Exercise Testing (FIT) Project, 167 patients had baseline HFpEF, defined as a clinical diagnosis of heart failure with ejection fraction ≥ 50% on echocardiogram. The CRF was estimated from the peak workload (in METs) from a clinician-referred treadmill stress test and categorized as poor (1-4 METs), intermediate (5-6 METs), and moderate-high (≥ 7 METs). Additional analyses assessing the effect of HFpEF and CRF on mortality were also conducted, matching HFpEF patients to non-HFpEF patients using propensity scores. RESULTS Mean age was 64 ±13 years, with 55% women, and 46% Black. Over a median follow-up of 9.7 (5.2-18.9) years, there were 103 deaths. In fully adjusted models, moderate-high CRF was associated with 63% lower mortality risk (HR = 0.37, 95% CI: 0.18-0.73) compared to the poor-CRF group. In the propensity-matched cohort, HFpEF was associated with a HR of 2.3 (95% CI: 1.7-3.2) for mortality compared to non-HFpEF patients, which was attenuated to 1.8 (95% CI: 1.3-2.5) after adjusting for CRF. CONCLUSIONS Moderate-high CRF in patients with HFpEF is associated with improved survival, and differences in CRF partly explain the intrinsic risk of HFpEF. Randomized trials of interventions aimed at improving CRF in HFpEF are needed.
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Affiliation(s)
- Olusola A. Orimoloye
- Ciccarone Center for the Prevention of Cardiovascular Disease, Johns Hopkins University School of Medicine, Baltimore, USA
| | - Swetha Kambhampati
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Albert J. Hicks
- Department of Medicine/Cardiology Division, Baylor Scott & White Health, Temple, USA
| | - Mahmoud Al Rifai
- Ciccarone Center for the Prevention of Cardiovascular Disease, Johns Hopkins University School of Medicine, Baltimore, USA
| | | | - Seamus Whelton
- Ciccarone Center for the Prevention of Cardiovascular Disease, Johns Hopkins University School of Medicine, Baltimore, USA
| | - Waqas Qureshi
- Division of Cardiovascular Medicine, Wake Forest University of Medicine, Winston Salem, NC, USA
| | - Jonathan K. Ehrman
- Division of Cardiovascular Medicine, Henry Ford Hospital, Detroit, MI, USA
| | - Steven J. Keteyian
- Division of Cardiovascular Medicine, Henry Ford Hospital, Detroit, MI, USA
| | - Clinton A. Brawner
- Division of Cardiovascular Medicine, Henry Ford Hospital, Detroit, MI, USA
| | - Zeina Dardari
- Ciccarone Center for the Prevention of Cardiovascular Disease, Johns Hopkins University School of Medicine, Baltimore, USA
| | - Mouaz H. Al-Mallah
- King Saud bin Abdulaziz University for Health Sciences, King Abdullah International Medical Research Center, King Abdulaziz Cardiac Center, Ministry of National Guard Health Affairs, Saudi Arabia
| | - Michael J. Blaha
- Ciccarone Center for the Prevention of Cardiovascular Disease, Johns Hopkins University School of Medicine, Baltimore, USA
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Schultheiss HP, Fairweather D, Caforio ALP, Escher F, Hershberger RE, Lipshultz SE, Liu PP, Matsumori A, Mazzanti A, McMurray J, Priori SG. Dilated cardiomyopathy. Nat Rev Dis Primers 2019; 5:32. [PMID: 31073128 PMCID: PMC7096917 DOI: 10.1038/s41572-019-0084-1] [Citation(s) in RCA: 344] [Impact Index Per Article: 68.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
Dilated cardiomyopathy (DCM) is a clinical diagnosis characterized by left ventricular or biventricular dilation and impaired contraction that is not explained by abnormal loading conditions (for example, hypertension and valvular heart disease) or coronary artery disease. Mutations in several genes can cause DCM, including genes encoding structural components of the sarcomere and desmosome. Nongenetic forms of DCM can result from different aetiologies, including inflammation of the myocardium due to an infection (mostly viral); exposure to drugs, toxins or allergens; and systemic endocrine or autoimmune diseases. The heterogeneous aetiology and clinical presentation of DCM make a correct and timely diagnosis challenging. Echocardiography and other imaging techniques are required to assess ventricular dysfunction and adverse myocardial remodelling, and immunological and histological analyses of an endomyocardial biopsy sample are indicated when inflammation or infection is suspected. As DCM eventually leads to impaired contractility, standard approaches to prevent or treat heart failure are the first-line treatment for patients with DCM. Cardiac resynchronization therapy and implantable cardioverter-defibrillators may be required to prevent life-threatening arrhythmias. In addition, identifying the probable cause of DCM helps tailor specific therapies to improve prognosis. An improved aetiology-driven personalized approach to clinical care will benefit patients with DCM, as will new diagnostic tools, such as serum biomarkers, that enable early diagnosis and treatment.
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Affiliation(s)
- Heinz-Peter Schultheiss
- Institute for Cardiac Diagnostics and Therapy (IKDT), Berlin, Germany. .,Department of Cardiology, Charité-Universitaetsmedizin Berlin, Berlin, Germany.
| | - DeLisa Fairweather
- Mayo Clinic, Department of Cardiovascular Medicine, Jacksonville, FL, USA.
| | - Alida L. P. Caforio
- 0000 0004 1757 3470grid.5608.bDivision of Cardiology, Department of Cardiological Thoracic and Vascular Sciences and Public Health, University of Padua, Padova, Italy
| | - Felicitas Escher
- grid.486773.9Institute for Cardiac Diagnostics and Therapy (IKDT), Berlin, Germany ,0000 0001 2218 4662grid.6363.0Department of Cardiology, Charité–Universitaetsmedizin Berlin, Berlin, Germany ,0000 0004 5937 5237grid.452396.fDZHK (German Centre for Cardiovascular Research), partner site Berlin, Berlin, Germany
| | - Ray E. Hershberger
- 0000 0001 2285 7943grid.261331.4Divisions of Human Genetics and Cardiovascular Medicine in the Department of Internal Medicine, The Ohio State University College of Medicine, Columbus, OH USA
| | - Steven E. Lipshultz
- 0000 0004 1936 9887grid.273335.3Department of Pediatrics, University at Buffalo Jacobs School of Medicine and Biomedical Sciences, Buffalo, NY USA ,0000 0000 9958 7286grid.413993.5Oishei Children’s Hospital, Buffalo, NY USA ,Roswell Park Comprehensive Cancer Center, Buffalo, NY USA
| | - Peter P. Liu
- 0000 0001 2182 2255grid.28046.38University of Ottawa Heart Institute, Ottawa, Ontario Canada
| | - Akira Matsumori
- grid.410835.bClinical Research Center, National Hospital Organization Kyoto Medical Center, Kyoto, Japan
| | - Andrea Mazzanti
- 0000 0004 1762 5736grid.8982.bDepartment of Molecular Medicine, University of Pavia, Pavia, Italy ,Department of Molecular Cardiology, IRCCS ICS Maugeri, Pavia, Italy
| | - John McMurray
- 0000 0001 2193 314Xgrid.8756.cBritish Heart Foundation (BHF) Cardiovascular Research Centre, University of Glasgow, Glasgow, UK
| | - Silvia G. Priori
- 0000 0004 1762 5736grid.8982.bDepartment of Molecular Medicine, University of Pavia, Pavia, Italy ,Department of Molecular Cardiology, IRCCS ICS Maugeri, Pavia, Italy
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Bozkurt B, Colvin M, Cook J, Cooper LT, Deswal A, Fonarow GC, Francis GS, Lenihan D, Lewis EF, McNamara DM, Pahl E, Vasan RS, Ramasubbu K, Rasmusson K, Towbin JA, Yancy C. Current Diagnostic and Treatment Strategies for Specific Dilated Cardiomyopathies: A Scientific Statement From the American Heart Association. Circulation 2016; 134:e579-e646. [PMID: 27832612 DOI: 10.1161/cir.0000000000000455] [Citation(s) in RCA: 449] [Impact Index Per Article: 56.1] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
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Kurl S, Mäkikallio T, Jae SY, Ronkainen K, Laukkanen JA. Exercise cardiac power and the risk of coronary heart disease and cardiovascular mortality in men. Ann Med 2016; 48:625-630. [PMID: 27684365 DOI: 10.1080/07853890.2016.1202444] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/20/2022] Open
Abstract
PURPOSE The aim of this study was to examine the relationship of exercise cardiac power (ECP), defined as a ratio of directly measured maximal oxygen uptake with peak systolic blood pressure during exercise, with the risk of mortality from coronary heart diseases (CHD) and cardiovascular diseases (CVD). DESIGN Population-based cohort study with an average follow-up of 25 years from eastern Finland. About 2358 men at baseline participated in exercise stress test and 182 CHD and 302 CVD deaths occurred. RESULTS Men with low ECP (< 8.7 mL/mmHg, lowest quartile) had a 3.5-fold (95% CI 2.1-5.8, p < 0.0001) risk of CHD mortality as compared with men with high ECP (>16.4 mL/mmHg, highest quartile) after adjusting for age and examination year. Low ECP was associated with a 2.8-fold risk of CHD and 2.4-fold for CVD mortality after additional adjustment for conventional risk factors. After further adjustment for leisure time physical activity, the results hardly changed (HR 2.5, 95% CI 1.71-3.67, p < 0.001). CONCLUSION ECP provides non-invasive and easily available measure for the prediction of CHD and CVD mortality. One of the most potential explanation for the association between ECP and the risk of CHD and CVD mortality is an elevated afterload and peripheral resistance indicated by hypertension. Key messages Index of exercise cardiac power defined as the ratio of directly measured maximal oxygen uptake (VO2max) with peak systolic blood pressure gives prognostic information in coronary heart disease (CHD) and CVD mortality risk stratification. ECP provides non-invasive and easily available measure for the prediction of CHD and CVD mortality. One of the most potential explanation for the association between ECP and the risk of CHD and CVD mortality is an elevated afterload and peripheral resistance indicated by hypertension.
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Affiliation(s)
- Sudhir Kurl
- a Institute of Public Health and Clinical Nutrition , University of Eastern Finland , Kuopio , Finland
| | - Timo Mäkikallio
- b Division of Cardiology, Department of Internal Medicine , University Hospital of Oulu , Oulu , Finland
| | - Sae Young Jae
- c Department of Sports Informatics, College of Arts and Physical Education , University of Seoul , South Korea
| | - Kimmo Ronkainen
- a Institute of Public Health and Clinical Nutrition , University of Eastern Finland , Kuopio , Finland
| | - Jari A Laukkanen
- a Institute of Public Health and Clinical Nutrition , University of Eastern Finland , Kuopio , Finland.,d Central Finland Hospital , Jyväskylä , Finland
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Kim HW, Ryu GW, Park CH, Kang EW, Park JT, Han SH, Yoo TH, Shin SK, Kang SW, Choi KH, Han DS, Chang TI. Hyponatremia Predicts New-Onset Cardiovascular Events in Peritoneal Dialysis Patients. PLoS One 2015; 10:e0129480. [PMID: 26053619 PMCID: PMC4460085 DOI: 10.1371/journal.pone.0129480] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2015] [Accepted: 05/09/2015] [Indexed: 12/01/2022] Open
Abstract
Background and Aim Cardiovascular (CV) disease is the leading cause of morbidity and mortality in patients on peritoneal dialysis (PD). Hyponatremia was recently shown to be a modifiable factor that is strongly associated with increased mortality in PD patients. However, the clinical impact of hyponatremia on CV outcomes in these patients is unclear. Methods To determine whether a low serum sodium level predicts the development of CV disease, we carried out a prospective observational study of 441 incident patients who started PD between January 2000 and December 2005. Time-averaged serum sodium (TA-Na) levels were determined to investigate the ability of hyponatremia to predict newly developed CV events in these patients. Results During a mean follow-up of 43.2 months, 106 (24.0%) patients developed new CV events. The cumulative incidence of new-onset CV events after the initiation of PD was significantly higher in patients with TA-Na levels ≤ 138 mEq/L than in those with a TA-Na > 138 mEq/L. After adjustment for multiple potentially confounding covariates, an increase in TA-Na level was found to be associated with a significantly lower risk of CV events (subdistribution hazard ratio per 1 mEq/L increase, 0.90; 95% confidence interval, 0.83–0.96; p = 0.003). Patients with a TA-Na ≤ 138 mEq/L had a 2.31-fold higher risk of suffering a CV event. Conclusions These results provide evidence of a clear association between low serum sodium and new-onset CV events after dialysis initiation in PD patients. Whether the correction of hyponatremia for this indication provides additional protection for the development of CV disease in these patients remains to be addressed in interventional studies.
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Affiliation(s)
- Hyung Woo Kim
- Department of Internal Medicine, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Geun Woo Ryu
- Department of Internal Medicine, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Cheol Ho Park
- Department of Internal Medicine, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Ea Wha Kang
- Department of Internal Medicine, NHIS Medical Center, Ilsan Hospital, Goyangshi, Gyeonggi-do, Republic of Korea
| | - Jung Tak Park
- Department of Internal Medicine, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Seung Hyeok Han
- Department of Internal Medicine, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Tae-Hyun Yoo
- Department of Internal Medicine, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Sug Kyun Shin
- Department of Internal Medicine, NHIS Medical Center, Ilsan Hospital, Goyangshi, Gyeonggi-do, Republic of Korea
| | - Shin-Wook Kang
- Department of Internal Medicine, Yonsei University College of Medicine, Seoul, Republic of Korea
- Brain Korea 21 for Medical Science, Severance Biomedical Science Institute, Yonsei University, Seoul, Republic of Korea
| | - Kyu Hun Choi
- Department of Internal Medicine, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Dae Suk Han
- Department of Internal Medicine, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Tae Ik Chang
- Department of Internal Medicine, NHIS Medical Center, Ilsan Hospital, Goyangshi, Gyeonggi-do, Republic of Korea
- * E-mail:
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Exercise cardiac power and the risk of sudden cardiac death in a long-term prospective study. Int J Cardiol 2015; 181:155-9. [DOI: 10.1016/j.ijcard.2014.12.023] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/22/2014] [Accepted: 12/01/2014] [Indexed: 11/16/2022]
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Giannoni A, Baruah R, Leong T, Rehman MB, Pastormerlo LE, Harrell FE, Coats AJS, Francis DP. Do optimal prognostic thresholds in continuous physiological variables really exist? Analysis of origin of apparent thresholds, with systematic review for peak oxygen consumption, ejection fraction and BNP. PLoS One 2014; 9:e81699. [PMID: 24475020 PMCID: PMC3903471 DOI: 10.1371/journal.pone.0081699] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2013] [Accepted: 10/15/2013] [Indexed: 11/22/2022] Open
Abstract
Background Clinicians are sometimes advised to make decisions using thresholds in measured variables, derived from prognostic studies. Objectives We studied why there are conflicting apparently-optimal prognostic thresholds, for example in exercise peak oxygen uptake (pVO2), ejection fraction (EF), and Brain Natriuretic Peptide (BNP) in heart failure (HF). Data Sources and Eligibility Criteria Studies testing pVO2, EF or BNP prognostic thresholds in heart failure, published between 1990 and 2010, listed on Pubmed. Methods First, we examined studies testing pVO2, EF or BNP prognostic thresholds. Second, we created repeated simulations of 1500 patients to identify whether an apparently-optimal prognostic threshold indicates step change in risk. Results 33 studies (8946 patients) tested a pVO2 threshold. 18 found it prognostically significant: the actual reported threshold ranged widely (10–18 ml/kg/min) but was overwhelmingly controlled by the individual study population's mean pVO2 (r = 0.86, p<0.00001). In contrast, the 15 negative publications were testing thresholds 199% further from their means (p = 0.0001). Likewise, of 35 EF studies (10220 patients), the thresholds in the 22 positive reports were strongly determined by study means (r = 0.90, p<0.0001). Similarly, in the 19 positives of 20 BNP studies (9725 patients): r = 0.86 (p<0.0001). Second, survival simulations always discovered a “most significant” threshold, even when there was definitely no step change in mortality. With linear increase in risk, the apparently-optimal threshold was always near the sample mean (r = 0.99, p<0.001). Limitations This study cannot report the best threshold for any of these variables; instead it explains how common clinical research procedures routinely produce false thresholds. Key Findings First, shifting (and/or disappearance) of an apparently-optimal prognostic threshold is strongly determined by studies' average pVO2, EF or BNP. Second, apparently-optimal thresholds always appear, even with no step in prognosis. Conclusions Emphatic therapeutic guidance based on thresholds from observational studies may be ill-founded. We should not assume that optimal thresholds, or any thresholds, exist.
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Affiliation(s)
- Alberto Giannoni
- International Centre for Circulatory Health, National Heart and Lung Institute, Imperial College, London, United Kingdom
- Department of Cardiovascular Medicine, Fondazione Toscana G. Monasterio, Pisa, Italy
- * E-mail:
| | - Resham Baruah
- International Centre for Circulatory Health, National Heart and Lung Institute, Imperial College, London, United Kingdom
| | - Tora Leong
- International Centre for Circulatory Health, National Heart and Lung Institute, Imperial College, London, United Kingdom
| | | | | | - Frank E. Harrell
- Vanderbilt University School of Medicine, Nashville, Tennessee, United States of America
| | - Andrew J. S. Coats
- International Centre for Circulatory Health, National Heart and Lung Institute, Imperial College, London, United Kingdom
- Norfolk and Norwich Hospital, University of East Anglia, Norwich, United Kingdom
| | - Darrel P. Francis
- International Centre for Circulatory Health, National Heart and Lung Institute, Imperial College, London, United Kingdom
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Gardner RS, McDonagh TA. The prognostic value of anemia, right-heart catheterization and neurohormones in chronic heart failure. Expert Rev Cardiovasc Ther 2014; 4:51-7. [PMID: 16375628 DOI: 10.1586/14779072.4.1.51] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Chronic heart failure is increasing in incidence and prevalence. Recent advances in medical therapy have improved prognosis such that, even in patients with chronic heart failure who are New York Heart Association Classes III and IV, annual mortality can be as low as 11.4%. Nevertheless, some patients remain at risk, despite optimal disease-modifying medical therapy, and it would seem appropriate that these patients are considered first for appropriate device therapy or for the scarce resource of cardiac transplantation. Many parameters have been assessed for their prognostic potential in patients with chronic heart failure. In this review, pertinent studies investigating anemia, right-heart hemodynamics and neurohormones as prognostic markers are discussed.
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Affiliation(s)
- Roy S Gardner
- Department of Cardiology, Royal Infirmary, Glasgow, G4 OSF, UK.
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12
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Hoorn EJ, Zietse R. Hyponatremia and mortality: moving beyond associations. Am J Kidney Dis 2013; 62:139-49. [PMID: 23291150 DOI: 10.1053/j.ajkd.2012.09.019] [Citation(s) in RCA: 138] [Impact Index Per Article: 12.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2012] [Accepted: 09/18/2012] [Indexed: 12/23/2022]
Abstract
Acute hyponatremia can cause death if cerebral edema is not treated promptly. Conversely, if chronic hyponatremia is corrected too rapidly, osmotic demyelination may ensue, which also potentially is lethal. However, these severe complications of hyponatremia are relatively uncommon and often preventable. More commonly, hyponatremia predicts mortality in patients with advanced heart failure or liver cirrhosis. In these conditions, it generally is assumed that hyponatremia reflects the severity of the underlying disease rather than contributing directly to mortality. The same assumption holds for the recently reported associations between hyponatremia and mortality in patients with pulmonary embolism, pulmonary hypertension, pneumonia, and myocardial infarction. However, recent data suggest that chronic and mild hyponatremia in the general population also are associated with mortality. In addition, hyponatremia has been associated with mortality in long-term hemodialysis patients without residual function in whom the underlying disease cannot be responsible for hyponatremia. These new data raise the question of whether hyponatremia by itself can contribute to mortality or it remains a surrogate marker for other unknown risk factors. We review hyponatremia and mortality and explore the possibility that hyponatremia perturbs normal physiology in the absence of cerebral edema or osmotic demyelination.
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Affiliation(s)
- Ewout J Hoorn
- Department of Internal Medicine-Nephrology, Erasmus Medical Center, Rotterdam, the Netherlands.
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Vallebona A, Gigli G, Orlandi S, Orlandi D, Gigli L, Reggiardo G. The etiology-filling pattern-pulmonary artery pressure score: a simple tool for risk stratification of patients with systolic heart failure. CONGESTIVE HEART FAILURE (GREENWICH, CONN.) 2013; 19:39-43. [PMID: 22507385 DOI: 10.1111/j.1751-7133.2012.00294.x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/31/2023]
Abstract
Heart failure (HF) is a leading cause of morbidity and mortality. The detection of patients at high risk for death is a major challenge in HF management. The authors compared the prognostic value of 23 clinical Doppler echocardiography and cardiopulmonary exercise indexes in a stable, moderately symptomatic, systolic HF outpatient population receiving optimal medical therapy. The end point was the incidence of overall mortality. Between January 2002 and December 2008, a total of 146 patients with left ventricular (LV) ejection fraction 0.31±0.8 and New York Heart Association functional class II or III were enrolled. The prognostic power of single variables was assessed using chi-square test for categoric variables and t test for continuous variables. Variables associated with the prespecified end point were included as predictors in a binary logistic regression multivariate model. At multivariate analysis, "restrictive" LV filling pattern (P=.004), ischemic etiology (P=.022), pulmonary artery systolic pressure (PASP) ≥50 mm Hg (P=.027), and peak oxygen uptake (VO(2) ) <15.9 mL/kg/min (P=.046) resulted independent predictors of the outcome. A simple risk score was then obtained using these significant independent variables, excluding peak VO(2) because of only borderline significance. Patients with ischemic etiology, restrictive LV filling pattern, and PASP ≥50 mm Hg have a very high risk of death (odds ratio, 33.77; 95% confidence interval, 5.74-198.8; P<.001, compared with patients with no risk factors). In this high-risk group, evaluation of peak VO(2) could be superfluous. A very simple clinical echocardiographic model based on etiology-LV filling and pulmonary pressure is a powerful tool for risk stratification of systolic HF in ambulatory patients.
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Affiliation(s)
- Marco Guazzi
- Heart Failure Unit, Cardiology, I.R.C.C.S., Policlinico San Donato, Department of Medical Sciences, University of Milano, Piazza Malan 1 20097, San Donato Milanese, Milano, Italy.
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Zaya M, Phan A, Schwarz ER. Predictors of re-hospitalization in patients with chronic heart failure. World J Cardiol 2012; 4:23-30. [PMID: 22379534 PMCID: PMC3289890 DOI: 10.4330/wjc.v4.i2.23] [Citation(s) in RCA: 41] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/18/2011] [Revised: 12/03/2011] [Accepted: 12/11/2011] [Indexed: 02/06/2023] Open
Abstract
Heart failure (HF) is a chronic, progressive illness that is highly prevalent in the United States and worldwide. This morbid illness carries a very poor prognosis, and leads to frequent hospitalizations. Repeat hospitalization in HF is both largely burdensome to the patient and the healthcare system, as it is one of the most costly medical diagnoses among Medicare recipients. For years, investigators have strived to determine methods to reduce hospitalization rates of HF patients. Despite such efforts, recent reports indicate that re-hospitalization rates remain persistently high, without any improvement over the past several years and thus, this topic clearly needs aggressive attention. We performed a key-word search of the literature for relevant citations. Published articles, limited to English abstracts indexed primarily in the PubMed database through the year 2011, were reviewed. This article discusses various clinical parameters, serum biomarkers, hemodynamic parameters, and psychosocial factors that have been reviewed in the literature as predictors of re-hospitalization of HF patients. With this information, our hope is that the future holds better risk-stratification models that will allow providers to identify high-risk patients, and better customize effective interventions according to the needs of each individual HF patient.
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Affiliation(s)
- Melody Zaya
- Melody Zaya, Anita Phan, Ernst R Schwarz, Cedars-Sinai Heart Institute, Cedars-Sinai Medical Center, Los Angeles, CA 90048, United States
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Baldasseroni S, Urso R, Orso F, Bianchini BP, Carbonieri E, Cirò A, Gonzini L, Leonardi G, Marchionni N, Maggioni AP. Relation between serum sodium levels and prognosis in outpatients with chronic heart failure: neutral effect of treatment with beta-blockers and angiotensin-converting enzyme inhibitors: data from the Italian Network on Congestive Heart Failure (IN-CHF database). J Cardiovasc Med (Hagerstown) 2012; 12:723-31. [PMID: 21873881 DOI: 10.2459/jcm.0b013e32834ae87e] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
INTRODUCTION The predictive role of hyponatremia has been tested in acute and chronic heart failure. Sodium level is inversely related with renin-angiotensin-aldersterone system (RAAS) and sympathetic nervous activity but important issues remain unresolved. Our aim was to define the level of hyponatremia able to predict 1-year outcomes and investigate the relation between sodium levels and mortality and the effect of beta-blockers and angiotensin-converting enzyme (ACE) inhibitors on this relation. METHODS We analyzed 4670 patients enrolled in the IN-CHF Italian Registry. We controlled the predictivity of hyponatremia, testing it either as a continuous variable and dividing the study sample into three severity groups: group 1 (≥136 mEq/l; n = 4207), group 2 (131-135 mEq/l; n = 389) and group 3 (≤130 mEq/l; n = 74). The linearity of the relationship between sodium levels and mortality was also tested. RESULTS Mild-to-moderate and severe hyponatremia (groups 2 and 3) independently predicted the 1-year mortality. The relation between sodium concentration and death was not linear and a decrease of 1 mEq/l of sodium increased death rate only for values of sodium 142.9 mEq/l or less. This relationship was not modified by beta-blocker and ACE inhibitor therapies. CONCLUSION Our data confirm the negative prognostic value of hyponatremia, even of moderate degree, independently of the use of recommended treatments for heart failure.
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Affiliation(s)
- Samuele Baldasseroni
- Section of Geriatric Cardiology, Department of Heart and Vessels, University School of Medicine, Florence and Careggi Hospital, Italy
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Tada Y, Nakamura T, Funayama H, Sugawara Y, Ako J, Ishikawa SE, Momomura SI. Early development of hyponatremia implicates short- and long-term outcomes in ST-elevation acute myocardial infarction. Circ J 2011; 75:1927-33. [PMID: 21617327 DOI: 10.1253/circj.cj-10-0945] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
BACKGROUND Clinical importance of hyponatremia in ST-elevation acute myocardial infarction (STEMI) in the era of primary intervention has not been fully understood. The aim of this study was to investigate the impact of hyponatremia on outcomes in patients with STEMI and secondarily to investigate the contribution of arginine vasopressin (AVP) to hyponatremia in STEMI. METHODS AND RESULTS Hyponatremia was defined as a sodium concentration <136 mmol/L at 72h after hospitalization. First, the short-term (in-hospital mortality or congestive heart failure (CHF)) and long-term prognosis (cardiac death, re-admission for CHF) in STEMI patients was conducted. Second, the relationship between serum sodium level and plasma AVP was investigated. In hyponatremic patients the incidence of in-hospital heart failure was significantly greater (P=0.0018), long-term cardiac death was a higher trend (17.2% vs. 6.3%, P=0.19) and re-admission due to CHF was significantly more frequent (20.7% vs. 4.5%, P=0.0024). Plasma AVP level was higher in the hyponatremia group (4.5 vs. 2.7 pg/ml, P=0.003), and it had a negative correlation with serum sodium level (r=-0.28, P=0.02). CONCLUSIONS Hyponatremia was frequently found in the early phase of STEMI, and associated with heart failure in both short- and long-term outcomes. Non-osmotic secretion of AVP could be involved in hyponatremia in STEMI patients.
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Affiliation(s)
- Yuko Tada
- Cardiovascular Division, Department of Medicine, Jichi Medical University, Saitama Medical Center, Saitama, Japan
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Havránek Š, Bělohlávek J, Škulec R, Kovárník T, Dytrych V, Linhart A. Long-term prognostic impact of hyponatremia in the ST-elevation myocardial infarction. Scandinavian Journal of Clinical and Laboratory Investigation 2010; 71:38-44. [DOI: 10.3109/00365513.2010.535012] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Affiliation(s)
- Štěpán Havránek
- 2nd Department of Medicine, Department of Cardiovascular Medicine, First Faculty of Medicine, Charles University and General University Hospital, Prague
| | - Jan Bělohlávek
- 2nd Department of Medicine, Department of Cardiovascular Medicine, First Faculty of Medicine, Charles University and General University Hospital, Prague
| | - Roman Škulec
- Emergency Medical Service of the Central Bohemian Region, Beroun, Czech Republic
| | - Tomáš Kovárník
- 2nd Department of Medicine, Department of Cardiovascular Medicine, First Faculty of Medicine, Charles University and General University Hospital, Prague
| | - Vladimír Dytrych
- 2nd Department of Medicine, Department of Cardiovascular Medicine, First Faculty of Medicine, Charles University and General University Hospital, Prague
| | - Aleš Linhart
- 2nd Department of Medicine, Department of Cardiovascular Medicine, First Faculty of Medicine, Charles University and General University Hospital, Prague
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A cutoff point for peak oxygen consumption in the prognosis of heart failure patients with beta-blocker therapy. Int J Cardiol 2010; 145:75-7. [DOI: 10.1016/j.ijcard.2009.05.001] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/29/2009] [Accepted: 05/01/2009] [Indexed: 11/19/2022]
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Barron AJ, Medlow KI, Giannoni A, Unsworth B, Coats AJS, Mayet J, Howard LS, Francis DP. Reduced confounding by impaired ventilatory function with oxygen uptake efficiency slope and VE/VCO2 slope rather than peak oxygen consumption to assess exercise physiology in suspected heart failure. ACTA ACUST UNITED AC 2010; 16:259-64. [PMID: 21091610 DOI: 10.1111/j.1751-7133.2010.00183.x] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
Heart failure and ventilatory disease often coexist; both create abnormalities in cardiopulmonary exercise test measurements. The authors evaluated the relative dependency of a well-recognized index of heart failure, peak oxygen consumption (VO(2)), and 2 newer indices, the minute ventilation (VE)/carbon dioxide production (VCO(2)) slope and oxygen uptake efficiency slope (OUES), on standard markers of impaired cardiac and ventilatory function. One hundred twenty-four patients (median age, 65.8; range, 22.6-84.9), with functional limitation from clinical heart failure were exercised. Peak VO(2) was 17.14 ± 7.58 mL/kg/min, VE/VCO(2) slope 50.1 ± 20.1, OUES 1.46 ± 0.68 L/min, and forced expiratory volume in 1 second (FEV(1) ) 1.88 ± 0.75 L. Peak VO(2) is substantially more sensitive to FEV(1) than ejection fraction (4.0 mL/kg/min difference between above- and below-median FEV(1) and 1.5 mL/kg/min between above- and below-median ejection fraction). OUES does not share this peculiar excess sensitivity to FEV(1) (0.12 L/min difference between above- and below-median FEV(1) and 0.01 L/min between above- and below-median ejection fraction). VE/VCO(2) slope has a borderline effect by FEV(1) (7.07 difference between above- and below-median FEV(1) and 2.07 between above- and below-median ejection fraction). Although widely used as a marker of heart failure severity, peak VO(2) is very sensitive to spirometry status and is indeed more affected by FEV(1) than by ejection fraction. OUES in contrast does not show this preferential sensitivity to impaired FEV(1).
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Affiliation(s)
- Anthony J Barron
- International Centre for Circulatory Health, Imperial College London and Imperial College NHS Trust, London, UK.
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Adhyapak SM. Effect of right ventricular function and pulmonary pressures on heart failure prognosis. ACTA ACUST UNITED AC 2010; 13:72-7. [PMID: 20377809 DOI: 10.1111/j.1751-7141.2009.00053.x] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
The relationship of right ventricular function and pulmonary systolic pressure in patients with congestive heart failure was evaluated to risk-stratify them. The study included 147 consecutive patients with symptomatic heart failure who underwent clinical and laboratory examination and echocardiography including Doppler tissue echocardiography. They were followed for a mean of 11.2+/-6.4 months. During follow-up, 16 patients died and 45 patients had nonfatal cardiac events. There were 60 readmissions for heart failure. Pulmonary artery systolic pressure and right ventricular systolic function were inversely related (r(2)=0.66, P<.001). On Cox multivariate survival analysis, early worsening of pulmonary arterial pressures was an independent prognostic predictor (hazard ratio, 0.44; confidence interval, 0.28-0.91, P=.024). The patients with pulmonary hypertension and right ventricular systolic dysfunction had the worst prognosis. The assessments of right ventricular function help to risk-stratify patients with heart failure. The early worsening of pulmonary hypertension is a powerful predictor of worse prognosis.
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Hyponatremia in cirrhosis answers and questions. J Clin Gastroenterol 2010; 44:157-8. [PMID: 19935084 DOI: 10.1097/mcg.0b013e3181c21b27] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/10/2022]
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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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Dini FL, Rosa GM, Fontanive P, Santonato V, Napoli AM, Ciuti M, Di Bello V. Combining blood flow and tissue Doppler imaging with N-terminal pro-type B natriuretic peptide for risk stratification of clinically stable patients with systolic heart failure. EUROPEAN JOURNAL OF ECHOCARDIOGRAPHY 2010; 11:333-40. [PMID: 20051423 DOI: 10.1093/ejechocard/jep207] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
AIMS This study was designed to ascertain whether the combination of Doppler assessment of the ratio of mitral blood flow to myocardial early diastolic velocities (E/E(m) ratio) and plasma N-terminal pro-type B natriuretic peptide (NT-proBNP) testing is useful to better stratify patients with stable systolic heart failure (HF). METHODS AND RESULTS A total of 362 outpatients with chronic systolic HF (left ventricular ejection fraction <or=45%) underwent clinical assessment, NT-proBNP testing, and comprehensive echo-Doppler study. The endpoint was all-cause mortality or HF-related hospital admissions (i.e. hospitalization for worsening HF, biventricular pacemaker implantation, or mitral valve surgery). Median follow-up duration was 25 months. Two hundred and fifty-nine patients were judged clinically stable by a Framingham's criteria-based HF score. In multivariate Cox's proportional hazards analysis, plasma NT-proBNP (P< 0.0001) and E/E(m) ratio (P= 0.04) were among the significant predictors of the combined endpoint. Survival free from cardiac mortality and HF-related hospitalization was 55% in patients with the E/E(m) ratio in the higher third (>or=12), 77% in those with the E/E(m) ratio in the intermediate third, and 86% in those with the E/E(m) ratio in the lower third (<or=7) (P< 0.0001). By stratifying patients according to NT-proBNP above the median, patients' outcome was predicted in 13 out of 17 in the intermediate third (P = 0.002) and in 9 out of 10 in the lower third of E/E(m) ratio (P= 0.005). CONCLUSION In patients with stable HF categorized according to the E/E(m) ratio, NT-proBNP testing improves risk stratification, particularly in those with minor degrees of diastolic dysfunction.
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Affiliation(s)
- Frank Lloyd Dini
- Unità Operativa Malattie Cardiovascolari 1, Dipartimento Cardio-toracico e Vascolare, Università degli Studi di Pisa, Azienda Ospedaliera-Universitaria Pisana, Via Paradisa, 2, 56124 Pisa, Italy.
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Sueyoshi E, Sakamoto I, Hayashida T, Uetani M. Quantification of enhancement of left ventricular myocardium in patients with dilated cardiomyopathy using delayed enhanced MR imaging. Comput Med Imaging Graph 2009; 33:547-52. [DOI: 10.1016/j.compmedimag.2009.05.005] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2008] [Revised: 02/24/2009] [Accepted: 05/15/2009] [Indexed: 10/20/2022]
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Khush KK, Tasissa G, Butler J, McGlothlin D, De Marco T. Effect of pulmonary hypertension on clinical outcomes in advanced heart failure: analysis of the Evaluation Study of Congestive Heart Failure and Pulmonary Artery Catheterization Effectiveness (ESCAPE) database. Am Heart J 2009; 157:1026-34. [PMID: 19464413 DOI: 10.1016/j.ahj.2009.02.022] [Citation(s) in RCA: 71] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/06/2008] [Accepted: 02/13/2009] [Indexed: 11/26/2022]
Abstract
BACKGROUND Pulmonary hypertension has been shown to predict hospitalizations and mortality in patients with heart failure. We aimed to define the prevalence of mixed pulmonary hypertension (MPH; mean pulmonary artery pressure > or = 25 mm Hg, pulmonary capillary wedge pressure >15 mm Hg, and pulmonary vascular resistance > or = 3 Wood units), identify clinical predictors of MPH, and determine whether MPH predicts adverse outcomes in patients hospitalized with severe heart failure. METHODS This is a subgroup analysis of patients assigned to pulmonary artery catheter placement in the Evaluation Study of Congestive Heart Failure and Pulmonary Artery Catheterization Effectiveness (ESCAPE) trial. Patients with and without MPH were compared with respect to baseline characteristics and clinical outcomes, including NYHA class, 6-minute walk distance, quality of life, days hospitalized, and 6-month mortality. RESULTS Of the 171 patients studied, 80 (47%) had MPH. Older age was the only significant predictor of MPH. MPH patients had lower cardiac index (1.8 +/- 0.5 L/min vs 2.1 +/- 0.5 L/min, P = .001) and higher systemic vascular resistance index (3,179 +/- 1,454 vs 2,550 +/- 927 dynes x s/cm5 x m2, P < .001) compared to those without MPH. Importantly, right ventricular function was relatively preserved (median RVSWI 8.7 gm-m/m2/beat) in MPH patients. There were no significant differences in clinical outcomes between the two groups. CONCLUSIONS Mixed pulmonary hypertension is common in patients hospitalized with advanced heart failure and is not associated with adverse short-term clinical outcomes over and above the poor prognosis of ADHF patients without MPH.
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Husain S, Pamboukian SV, Tallaj JA, McGiffin DC, Bourge RC. Invasive monitoring in patients with heart failure. Curr Cardiol Rep 2009; 11:159-66. [PMID: 19379635 DOI: 10.1007/s11886-009-0024-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: 11/29/2022]
Abstract
The syndrome of heart failure is characterized by symptoms that are relatively insensitive and nonspecific. Physical diagnosis may be unreliable even in the hands of experienced clinicians, despite the presence of significantly elevated filling pressures or a significantly depressed cardiac output. Instrumentation and devices such as the insertion of a pulmonary artery catheter and the implantable hemodynamic monitor have a major role in the diagnosis and management of cardiovascular disease. They provide a means of measuring intracardiac pressures for point-in-time measurements (cardiac catheterization), short term in an acute situation (insertion of a pulmonary arterial catheter), and, more recently, a long-term assessment increasing our understanding of the nuances of the hemodynamic derangements associated with heart failure and other conditions. With improved ability to accurately assess and monitor filling pressures, clinicians can more precisely adjust therapy with the goal of improving patient symptoms and possibly outcomes.
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Affiliation(s)
- Saima Husain
- Division of Cardiovascular Disease, Department of Medicine, University of Alabama at Birmingham, 311 THT, 1900 University Boulevard, Birmingham, AL 35294, USA
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Hossein-Nia M, Baig K, Goldman JH, Keeling PJ, Caforio AL, Holt DW, McKenna WJ. Creatine kinase isoforms as circulating markers of deterioration in idiopathic dilated cardiomyopathy. Clin Cardiol 2009; 20:55-60. [PMID: 8994739 PMCID: PMC6656144 DOI: 10.1002/clc.4960200112] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023] Open
Abstract
BACKGROUND A proportion of patients with dilated cardiomyopathy (DCM) may have ongoing myocardial damage secondary to viral or immune mediated myocardial inflammation. HYPOTHESIS The prognostic determinants identify patients with decreased survival but do not provide a measure of myocardial damage. To obtain an objective assessment of myocardial damage in DCM, we measured plasma levels of creatine kinase (CK), its isoenzymes (CK-MM and CK-MB), and separated the isoforms of CK-MM and CK-MB. METHODS The cohort consisted of 77 consecutive patients (61 men, 16 women) with DCM (World Health Organization criteria), aged 49 +/- 14 years (range 19-60). Patients had been symptomatic for 29 +/- 38 months (range 0.5-200 months) with 48 in New York Heart Association class I/II and 29 in class III/IV at the time of diagnosis. During median follow-up of 27 months from diagnosis (range 0.6-165), 50 patients remained clinically stable and 27 had deteriorated. RESULTS A significantly higher proportion of patients with DCM had abnormal MB2/MB1 ratio compared with normal volunteers (11, 14% vs. 1,1%, p = 0.003). Patients who deteriorated had higher MB2/MB1 ratio, (1.22 +/- 0.62 vs. 0.85 +/- 0.56; p = 0.01), and more frequently had abnormal MB2/ MB1 ratio (8, 30% vs. 3, 6%; p = 0.004) and CK and CK-MM activities (5, 19% vs. 2, 4%; p = 0.03) than those who remained stable. Patients with DCM with high CK-MB activity had 3.13-fold increased odds of sudden death or need for cardiac transplantation (95% confidence interval 1.53-6.40, p = 0.008). Thus, CK measurements, in particular CK-MB isoforms, are markers of myocardial damage in a subset of patients with DCM and could be useful in investigating the possibility of persistent myocardial damage in these patients.
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Affiliation(s)
- M Hossein-Nia
- Department of Cardiological Sciences, St. George's Hospital Medical School, London, U.K
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Theodoropoulos TA, Bestetti RB, Otaviano AP, Cordeiro JA, Rodrigues VC, Silva AC. Predictors of all-cause mortality in chronic Chagas' heart disease in the current era of heart failure therapy. Int J Cardiol 2008; 128:22-9. [DOI: 10.1016/j.ijcard.2007.11.057] [Citation(s) in RCA: 48] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/27/2007] [Accepted: 11/12/2007] [Indexed: 10/22/2022]
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Combined longitudinal and radial dyssynchrony predicts ventricular response after resynchronization therapy. J Am Coll Cardiol 2007; 50:1476-83. [PMID: 17919568 DOI: 10.1016/j.jacc.2007.06.043] [Citation(s) in RCA: 205] [Impact Index Per Article: 12.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/26/2007] [Revised: 06/21/2007] [Accepted: 06/25/2007] [Indexed: 11/22/2022]
Abstract
OBJECTIVES The purpose of this study was to test the hypothesis that a combined echocardiographic assessment of longitudinal dyssynchrony by tissue Doppler imaging (TDI) and radial dyssynchrony by speckle-tracking strain may predict left ventricular (LV) functional response to cardiac resynchronization therapy (CRT). BACKGROUND Mechanical LV dyssynchrony is associated with response to CRT; however, complex patterns may exist. METHODS We studied 190 heart failure patients (ejection fraction [EF] 23 +/- 6%, QRS duration 168 +/- 27 ms) before and after CRT. Longitudinal dyssynchrony was assessed by color TDI for time to peak velocity (2 sites in all and 12 sites in a subgroup of 67). Radial dyssynchrony was assessed by speckle-tracking radial strain. The LV response was defined as > or =15% increase in EF. RESULTS One hundred seventy-six patients (93%) had technically sufficient baseline and follow-up data available. Overall, 34% were EF nonresponders at 6 +/- 3 months after CRT. When both longitudinal dyssynchrony by 2-site TDI (> or =60 ms) and radial dyssynchrony (> or =130 ms) were positive, 95% of patients had an EF response; when both were negative, 21% had an EF response (p < 0.001 vs. both positive). The EF response rate was lowest (10%) when dyssynchrony was negative using 12-site TDI and radial strain (p < 0.001 vs. both positive). When either longitudinal or radial dyssynchrony was positive (but not both), 59% had an EF response. Combined longitudinal and radial dyssynchrony predicted EF response with 88% sensitivity and 80% specificity, which was significantly better than either technique alone (p < 0.0001). CONCLUSIONS Combined patterns of longitudinal and radial dyssynchrony can be predictive of LV functional response after CRT.
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Norozi K, Bahlmann J, Raab B, Alpers V, Arnhold JO, Kuehne T, Klimes K, Zoege M, Geyer S, Wessel A, Buchhorn R. A prospective, randomized, double-blind, placebo controlled trial of beta-blockade in patients who have undergone surgical correction of tetralogy of Fallot. Cardiol Young 2007; 17:372-9. [PMID: 17572925 DOI: 10.1017/s1047951107000844] [Citation(s) in RCA: 49] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
AIMS Our purpose was to evaluate the effect of a treatment over six months with bisoprolol on the surrogate parameters of N-Terminal-pro brain natriuretic peptide, subsequently to be described as brain natriuretic peptide, peak uptake of oxygen, and ventricular function assessed by magnetic resonance imaging in grown ups and adults who had undergone surgical correction of tetralogy of Fallot. METHODS AND RESULTS We designed a prospective, randomized, double-blind, placebo controlled trial. We enrolled 33 patients, aged 30.9 plus or minus 9.5 years in either class 1 or 2 of the grading of the New York Heart Association class with both levels of brain natriuretic peptide greater than 100 pg/ml and a reduced peak uptake of oxygen less than 25 ml/kg/min. During treatment with Bisoprolol, the levels of brain natriuretic peptide increased significantly from 206 plus or minus 95 to 341 plus or minus 250 pg/ml (p< 0.05), and those of atrial natriuretic peptide from 4117 plus or minus 1837 to 5340 plus or minus 2102 fmol/ml (p = 0.0005). These measures remained unchanged in the group of patients receiving the placebo. Peak uptake of oxygen did not differ significantly in either group, nor did treatment have any significant effect on right and left ventricular volumes and ejection fractions as determined by magnetic resonance imaging. The clinical state as judged within the grading system of the New York Heart Association was also unchanged by beta-blockade. CONCLUSION Beta blockade with Bisoprolol seems to have no beneficial effect on asymptomatic or mildly symptomatic patients with right ventricular dysfunction secondary to repaired tetralogy of Fallot with residual pulmonary regurgitation and/or stenosis.
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Affiliation(s)
- Kambiz Norozi
- Department of Paediatric Cardiology and Intensive Care, Germany
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34
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Abstract
Despite advances in the therapy of cardiovascular disorders, heart failure remains a challenging disease with a dismal prognosis. A plethora of variables have been shown to be related to survival in patients with heart failure. These include heart failure etiology, clinical presentation, ventricular performance, exercise capacity, neurohormones and, more recently, inflammatory and necrosis markers. In this review we briefly list established predictive markers and discuss whether survival can accurately be predicted in this condition.
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Affiliation(s)
- Viorel G Florea
- Heart Failure Program, VA Medical Center, One Veterans Drive, 111-C, Minneapolis, MN 55417, USA
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35
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Yamokoski LM, Hasselblad V, Moser DK, Binanay C, Conway GA, Glotzer JM, Hartman KA, Stevenson LW, Leier CV. Prediction of Rehospitalization and Death in Severe Heart Failure by Physicians and Nurses of the ESCAPE Trial. J Card Fail 2007; 13:8-13. [PMID: 17338997 DOI: 10.1016/j.cardfail.2006.10.002] [Citation(s) in RCA: 77] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2006] [Revised: 09/29/2006] [Accepted: 10/06/2006] [Indexed: 11/21/2022]
Abstract
BACKGROUND The predictive accuracy of physician investigators and nurse coordinators in estimating the risk of rehospitalization and death was determined for 373 hospitalized patients with severe advanced heart failure enrolled in the Evaluation Study of Congestive Heart Failure and Pulmonary Artery Catheterization Effectiveness trial. METHODS AND RESULTS Estimates were made at discharge, and patients were followed for 6 months after hospitalization. A statistical prognostic model was developed from clinical and laboratory data for the end points of rehospitalization and death. Both nurse and physician predictions of death were generally associated with the observed deaths (c-indices of 0.675 and 0.611), although the nurses' prediction was significantly better (chi-square = 4.75, P = .029). The prediction ability of the prognostic model was similar to the physicians' model (c-index = 0.603). The predictions of rehospitalization were much weaker for nurse, physician and prognostic models. CONCLUSIONS Nurses' estimations of survival in discharged, advanced-stage heart failure patients were superior to either physicians' or model-based predictions. Not nurses, physicians, or the prognostic model provided useful predictions for rehospitalizations, but this may have resulted from the fact that the rehospitalization estimates did not include the death risk.
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36
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37
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Combined prognostic value of peak O(2) uptake and microvolt level T-wave alternans in patients with idiopathic dilated cardiomyopathy. Int J Cardiol 2006; 121:23-9. [PMID: 17188766 DOI: 10.1016/j.ijcard.2006.10.026] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/15/2006] [Revised: 08/08/2006] [Accepted: 10/14/2006] [Indexed: 01/28/2023]
Abstract
BACKGROUND Despite the great improvement in clinical management of patients with idiopathic dilated cardiomyopathy (DCM), sudden cardiac death (SCD) and death due to worsening heart failure (HF) remain a challenging problem. The assessment of oxygen consumption (peakVO(2)) has been recognized as an independent marker of mortality. Nevertheless peakVO(2) is not helpful in the risk stratification of SCD. Given this limitation, the association with another non-invasive test able to predict SCD such as microvolt level T-wave alternans (MTWA) would be useful. OBJECTIVES To determine the combined predictive value of peakVO(2) and MTWA in patients with DCM. METHODS Seventy consecutive DCM patients were prospectively investigated. PeakVO(2) and MTWA were determined during bicycle exercise testing. Primary composite study end-point was defined as major cardiac events (MCE): total cardiac death or documented sustained VT/VF (including appropriate ICD shock). Secondary end-point was defined as arrhythmic events (AE): SCD or documented sustained VT/VF. RESULTS Thirty-nine patients (55%) had a peakVO(2)<10 ml/kg/min, while 40 patients (57%) showed an abnormal MTWA test. During an average follow-up of 19.2+/-10.7 months, 11 MCE of which 6 AE have been documented. Among patients with abnormal MTWA and peakVO(2)<10 ml/kg/min 8 MCE of which 5 AE occurred while among patients with normal MTWA and peakVO(2)> or =10 ml/kg/min no event occurred. From multivariate analysis, the combined prognostic value of MTWA and peakVO(2) achieved statistical significance for MCE (p=0.03, HR 0.28, 95% CI 0.12-0.95) and for AE (p=0.05, HR 0.39, 95% CI 0.18-0.99) while MTWA alone was a significant predictor of AE (p=0.04, HR 0.32, 95% CI 0.14-0.93). CONCLUSIONS Our results suggest that only the association of MTWA and peakVO(2), but not the two single tests, is a significant prognostic marker of both MCE and AE in DCM patients. However, MTWA alone confirms its predictive power as arrhythmic risk stratifier in this population.
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38
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Mechanisms of idiopathic dilated cardiomyopathies. Curr Opin Organ Transplant 2006. [DOI: 10.1097/01.mot.0000244643.62599.9e] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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39
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Abstract
Right heart catheterization (RHC) has remained the gold standard in diagnosing elevated cardiac filling pressures. Despite advances in medical therapy, patients with persistent volume overload and heart failure (HF) have a poor prognosis. The diagnosis of volume overload can be difficult in advanced HF with clinical symptoms and signs often lacking sensitivity and specificity. Hemodynamic measurements at rest, especially pulmonary capillary wedge pressure and change in pulmonary capillary wedge pressure, have been closely linked to prognosis. However, RHC is invasive with attendant risks of complications. Noninvasive models without using catheterization-derived values have been shown to be equally predictive of survival. In selected clinical situations, especially the cardiorenal syndrome, RHC continues to play an important role. Newer invasive and noninvasive techniques to assess volume status are available, but large prospective trials are lacking. The advantage with continuous hemodynamic monitoring could be the development of an early warning system prior to the onset of symptomatic decompensation.
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Affiliation(s)
- Michael Craig
- Medical University of South Carolina, Charleston, SC 29425, USA
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40
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Moazami N, Shah NR, Ewald GA, Geltman EM, Moorhead SL, Pasque MK. Should UNOS Status 2 Patients Undergo Transplantation? Heart Surg Forum 2006; 9:E823-7. [PMID: 16893757 DOI: 10.1532/hsf98.20061061] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
BACKGROUND With recent improvements in medical and device therapy, the benefit of cardiac transplantation for UNOS Status 2 patients has been questioned. No randomized trial has been performed to compare transplantation versus contemporary medical therapy. METHODS Between January 1996 and December 2003, 203 patients were listed at our institution for heart transplantation as UNOS Status 2. We performed a retrospective review to determine outcomes in these patients. RESULTS Demographics of this cohort revealed a mean age of 52 years, female sex in 28%, and ischemic etiology in 47%. Eighty-one patients (40%) had an implantable cardiac defibrillator. A total of 64 patients (32%) had to be upgraded in their UNOS status, with 9 requiring a left ventricular assist device. Of the entire group, 95 (47%) underwent transplantation at a mean time of 303 days, 45 (22%) died while waiting at a mean time of 397 days, and 24 (12%) were removed from the waiting list due to deterioration in medical condition such that transplantation was no longer an option. The remaining patients continue to wait or have been removed from consideration due to improved condition. Survival at 1- and 3-years postlisting was 94% and 87% for patients who received transplants compared to 81% and 57% for patients who did not receive transplants (P < .01). CONCLUSION A significant number of patients listed as Status 2 are upgraded in UNOS status or die while on the waiting list. Early and midterm survival is significantly better with transplantation. Identification of variables associated with deterioration may allow for better risk stratification in the future. At this point, transplantation offers the best outcome.
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Affiliation(s)
- Nader Moazami
- Divisions of Cardiothoracic Surgery, Washington University School of Medicine, St. Louis, Missouri 63110, USA.
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41
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Suffoletto MS, Dohi K, Cannesson M, Saba S, Gorcsan J. Novel speckle-tracking radial strain from routine black-and-white echocardiographic images to quantify dyssynchrony and predict response to cardiac resynchronization therapy. Circulation 2006; 113:960-8. [PMID: 16476850 DOI: 10.1161/circulationaha.105.571455] [Citation(s) in RCA: 603] [Impact Index Per Article: 33.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
BACKGROUND Mechanical dyssynchrony is a potential means to predict response to cardiac resynchronization therapy (CRT). We hypothesized that novel echocardiographic image speckle tracking can quantify dyssynchrony and predict response to CRT. METHODS AND RESULTS Seventy-four subjects were studied: 64 heart failure patients undergoing CRT (aged 64+/-12 years, ejection fraction 26+/-6%, QRS duration 157+/-28 ms) and 10 normal controls. Speckle tracking applied to routine midventricular short-axis images calculated radial strain from multiple circumferential points averaged to 6 standard segments. Dyssynchrony from timing of speckle-tracking peak radial strain was correlated with tissue Doppler measures in 47 subjects (r=0.94, P<0.001; 95% CI 0.90 to 0.96). The ability of baseline speckle-tracking radial dyssynchrony (time difference in peak septal wall-to-posterior wall strain > or =130 ms) to predict response to CRT was then tested. It predicted an immediate increase in stroke volume in 48 patients studied the day after CRT with 91% sensitivity and 75% specificity. In 50 patients with long-term follow-up 8+/-5 months after CRT, baseline speckle-tracking radial dyssynchrony predicted a significant increase in ejection fraction with 89% sensitivity and 83% specificity. Patients in whom left ventricular lead position was concordant with the site of latest mechanical activation by speckle-tracking radial strain had an increase in ejection fraction from baseline to a greater degree (10+/-5%) than patients with discordant lead position (6+/-5%; P<0.05). CONCLUSIONS Speckle-tracking radial strain can quantify dyssynchrony and predict immediate and long-term response to CRT and has potential for clinical application.
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Affiliation(s)
- Matthew S Suffoletto
- The Cardiovascular Institute, University of Pittsburgh, Pittsburgh, PA 15213-2582, USA
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42
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Solomon SD, Anavekar N, Skali H, McMurray JJV, Swedberg K, Yusuf S, Granger CB, Michelson EL, Wang D, Pocock S, Pfeffer MA. Influence of ejection fraction on cardiovascular outcomes in a broad spectrum of heart failure patients. Circulation 2005; 112:3738-44. [PMID: 16330684 DOI: 10.1161/circulationaha.105.561423] [Citation(s) in RCA: 582] [Impact Index Per Article: 30.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Left ventricular function is a principal determinant of cardiovascular risk in patients with heart failure. The growing number of patients with preserved systolic function heart failure underscores the importance of understanding the relationship between ejection fraction and risk. METHODS AND RESULTS We studied 7599 patients with a broad spectrum of symptomatic heart failure enrolled in the Candesartan in Heart failure: Assessment of Reduction in Mortality and morbidity (CHARM) Program. All patients were randomized to candesartan at a target dose of 32 mg once daily or matching placebo and followed up for a median of 38 months. We related left ventricular ejection fraction (LVEF), measured before randomization at the sites, to cardiovascular outcomes and causes of death. Mean LVEF in patients enrolled in CHARM was 38.8+/-14.9% (median LVEF 36%). Patients with lower LVEF tended to have higher baseline New York Heart Association class. The hazard ratio for all-cause mortality increased by 39% for every 10% reduction in ejection fraction below 45% (hazard ratio 1.39, 95% CI 1.32 to 1.46), with adjustment for baseline covariates. All-cause mortality, cardiovascular death, and all components of cardiovascular death declined with increasing ejection fraction until an ejection fraction of 45%, after which the risk of these outcomes remained relatively stable with increasing LVEF. The absolute change in rate per 100 patient-years for each 10% reduction in LVEF was greatest for sudden death and heart failure-related death. The effect of candesartan in reducing cardiovascular outcomes was consistent across LVEF categories. CONCLUSIONS LVEF is a powerful predictor of cardiovascular outcome in heart failure patients across a broad spectrum of ventricular function. Nevertheless, once elevated to a range above 45%, ejection fraction does not further contribute to assessment of cardiovascular risk in heart failure patients.
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Affiliation(s)
- Scott D Solomon
- Cardiovascular Division, Department of Medicine, Brigham and Women's Hospital, Boston, MA 02445, USA
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43
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Nikitin NP, Loh PH, Silva RD, Ghosh J, Khaleva OY, Goode K, Rigby AS, Alamgir F, Clark AL, Cleland JGF. Prognostic value of systolic mitral annular velocity measured with Doppler tissue imaging in patients with chronic heart failure caused by left ventricular systolic dysfunction. Heart 2005; 92:775-9. [PMID: 16251233 PMCID: PMC1860660 DOI: 10.1136/hrt.2005.067140] [Citation(s) in RCA: 91] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
OBJECTIVE To assess the prognostic value of various conventional and novel echocardiographic indices in patients with chronic heart failure (CHF) caused by left ventricular (LV) systolic dysfunction. METHODS 185 patients with a mean (SD) age of 67 (11) years with CHF and LV ejection fraction < 45% despite optimal pharmacological treatment were prospectively enrolled. The patients underwent two dimensional echocardiography with tissue harmonic imaging to assess global LV systolic function and obtain volumetric data. Transmitral flow was assessed with conventional pulse wave Doppler. Systolic (Sm), early, and late diastolic mitral annular velocities were measured with the use of colour coded Doppler tissue imaging. RESULTS During a median follow up of 32 months (range 24-38 months in survivors), 34 patients died and one underwent heart transplantation. Sm velocity (hazard ratio (HR) 0.648, 95% confidence interval (CI) 0.463 to 0.907, p = 0.011), diastolic arterial pressure (HR 0.965, 95% CI 0.938 to 0.993, p = 0.015), serum creatinine (HR 1.006, 95% CI 1.001 to 1.011, p = 0.023), LV ejection fraction (HR 0.945, 95% CI 0.899 to 0.992, p = 0.024), age (HR 1.035, 95% CI 1.000 to 1.071, p = 0.052), LV end systolic volume index (HR 1.009, 95% CI 0.999 to 1.019, p = 0.067), and restrictive pattern of transmitral flow (HR 0.543, 95% CI 0.278 to 1.061, p = 0.074) predicted the outcome of death or transplantation on univariate analysis. On multivariate analysis, only Sm velocity (HR 0.648, 95% CI 0.460 to 0.912, p = 0.013) and diastolic arterial pressure (HR 0.966, 95% CI 0.938 to 0.994, p = 0.016) emerged as independent predictors of outcome. CONCLUSIONS In patients with CHF and LV systolic dysfunction despite optimal pharmacological treatment, the strongest independent echocardiographic predictor of prognosis was Sm velocity measured with quantitative colour coded Doppler tissue imaging.
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Affiliation(s)
- N P Nikitin
- Department of Cardiology, The University of Hull, Kingston-upon-Hull HU16 5JQ, UK.
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Adamson PB. Ambulatory Hemodynamics in Patients With Chronic Heart Failure: Implications for Volume Management in Elderly Patients. ACTA ACUST UNITED AC 2005; 14:236-41. [PMID: 16247282 DOI: 10.1111/j.1076-7460.2005.02596.x] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/23/2023]
Abstract
Invasive hemodynamic assessment of patients with chronic heart failure is helpful in managing severe congestive symptoms associated with acute volume exacerbations that lead to hospitalizations. Information useful in guiding medication changes targeting control of left ventricular filling pressures can be obtained from measurements in the right ventricle. With the advent of implantable devices designed to treat heart failure, the logical next development is an implanted device that incorporates sophisticated monitoring systems capable of continuous acquisition of hemodynamic information over a long-term period. An implantable hemodynamic monitoring system (Chronicle; Medtronic, Inc., Minneapolis, MN) is safe to implant and has a pressure sensor with proven long-term reliability. Using transtelephonic data transmission and Internet-based information systems, ambulatory hemodynamic monitoring may reduce the need for hospitalizations and overall health care utilization in patients with symptomatic heart failure. This approach may be especially helpful for elderly patients with chronic heart failure in whom overdiuresis or volume contraction may lead to gait instability and falls. Additionally, elderly patients with heart failure from primary diastolic dysfunction may have a very narrow therapeutic window of optimal volume that is difficult to assess by daily weights and physical examination alone. This hypothesis is currently being tested in a prospective randomized clinical trial.
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Affiliation(s)
- Philip B Adamson
- Department of Medicine, University of Oklahoma Health Sciences Center, Oklahoma City, OK 73120, USA.
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45
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Klein L, O'Connor CM, Leimberger JD, Gattis-Stough W, Piña IL, Felker GM, Adams KF, Califf RM, Gheorghiade M. Lower serum sodium is associated with increased short-term mortality in hospitalized patients with worsening heart failure: results from the Outcomes of a Prospective Trial of Intravenous Milrinone for Exacerbations of Chronic Heart Failure (OPTIME-CHF) study. Circulation 2005; 111:2454-60. [PMID: 15867182 DOI: 10.1161/01.cir.0000165065.82609.3d] [Citation(s) in RCA: 401] [Impact Index Per Article: 21.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
BACKGROUND The prognostic value of serum sodium in patients hospitalized for worsening heart failure has not been well defined. METHODS AND RESULTS The Outcomes of a Prospective Trial of Intravenous Milrinone for Exacerbations of Chronic Heart Failure (OPTIME-CHF) study randomized 949 patients with systolic dysfunction hospitalized for worsening heart failure to receive 48 to 72 hours of intravenous milrinone or placebo in addition to standard therapy. In a retrospective analysis, we investigated the relationship between admission serum sodium and the primary end point of days hospitalized for cardiovascular causes within 60 days of randomization, as well as the secondary end points of in-hospital mortality, 60-day mortality, and 60-day mortality/rehospitalization. The number of days hospitalized for cardiovascular causes was higher in the lowest sodium quartile: 8.0 (4.5, 18.5) versus 6 (4, 13) versus 6 (4, 11.5) versus 6 (4, 12) days (P<0.015 for comparison with the lowest quartile). Lower serum sodium was associated with higher in-hospital and 60-day mortality: 5.9% versus 1% versus 2.3% versus 2.3% (P<0.015) and 15.9% versus 6.4% versus 7.8% versus 7% (P=0.002), respectively. There was a trend toward higher mortality/rehospitalization for patients who were in the lowest sodium quartile. Multivariable-adjusted Cox proportional hazards analysis showed that serum sodium on admission, when modeled linearly, predicted increased 60-day mortality: sodium (per 3-mEq/L decrease) had a hazard ratio of 1.18 with a 95% CI of 1.03 to 1.36 (P=0.018). CONCLUSIONS In patients hospitalized for worsening heart failure, admission serum sodium is an independent predictor of increased number of days hospitalized for cardiovascular causes and increased mortality within 60 days of discharge.
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Affiliation(s)
- Liviu Klein
- Northwestern University Feinberg School of Medicine, Chicago, Ill 60611, USA
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46
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Kurl S, Laukkanen JA, Niskanen L, Rauramaa R, Tuomainen TP, Sivenius J, Salonen JT. Cardiac Power During Exercise and the Risk of Stroke in Men. Stroke 2005; 36:820-4. [PMID: 15705936 DOI: 10.1161/01.str.0000157592.82198.28] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background and Purpose—
Low maximal oxygen uptake (VO
2max
) has been shown to predict the risk of stroke. However, VO
2max
does not take into account the differences in cardiac afterload between subjects. The aim of this study was to examine the relationship of exercise cardiac power (ECP), defined as a ratio of VO
2max
with peak systolic blood pressure (SBP) during exercise, with the risk for stroke.
Methods—
Population-based cohort study with an average follow-up of 12 years from eastern Finland. A total of 1761 men with no history of stroke or coronary heart disease at baseline participated. Among these men, 91 strokes occurred, of which 69 were attributable to ischemic causes.
Results—
The relative risk of any stroke in men with low ECP (<10.3 mL/mm Hg) was 2.7 (95% CI, 1.2 to 6.0;
P
=0.01;
P
=0.02 for the trend across the quartiles), and the relative risk for ischemic stroke was 2.7 (95% CI, 1.1 to 7.0;
P
=0.03;
P
=0.04 for trend across the quartiles) compared with men having high ECP (>14.3 mL/mm Hg) during exercise after adjusting for age, examination year, cigarette smoking, alcohol consumption, body mass index, diabetes, serum total cholesterol level, energy expenditure of physical activity, exercise-induced myocardial ischemia, and the use of antihypertensive medication. After further adjustment for resting SBP, results were statistically nonsignificant.
Conclusions—
Low ECP provides noninvasive and easily available measure for stroke risk. One of the most potential explanations for the association between ECP and the increased risk of stroke is an elevated afterload and peripheral resistance indicated by elevated SBP.
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Affiliation(s)
- S Kurl
- Research Institute of Public Health, University of Kuopio, Kuopio, Finland.
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47
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Gardner RS, Henderson G, McDonagh TA. The prognostic use of right heart catheterization data in patients with advanced heart failure: How relevant are invasive procedures in the risk stratification of advanced heart failure in the era of neurohormones? J Heart Lung Transplant 2005; 24:303-9. [PMID: 15737757 DOI: 10.1016/j.healun.2004.01.010] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2003] [Revised: 11/30/2003] [Accepted: 01/20/2004] [Indexed: 11/16/2022] Open
Abstract
BACKGROUND Right heart catheterization long has been a routine investigation in advanced heart failure, and its measurements have been linked variably to prognosis. However, in the modern era, newer potential markers of prognosis are coming to light. This study reconsiders the use of right heart catheterization data and compares their use to that of N-terminal pro-brain natriuretic peptide (NT-proBNP), a neurohormone linked with prognosis in chronic heart failure. METHODS We assessed prospectively the prognostic potential of baseline right heart catheterization data in 97 consecutive patients with advanced heart failure referred to the Scottish Cardiopulmonary Transplant Unit for consideration of cardiac transplantation. Patients underwent baseline routine investigation, including right heart catheterization and blood draws for NT-proBNP analysis. Patients were observed for a median of 370 days. RESULTS The primary end-point of all-cause mortality was reached in 17 patients (17.5%), and the secondary end-point of all-cause mortality or urgent cardiac transplantation was reached in 21 (21.6%) patients. Univariate predictors of all-cause mortality included pulmonary artery systolic pressure (PASP), pulmonary artery wedge pressure (PAWP), and NT-proBNP concentration greater than their median values. Univariate predictors of the secondary end-point included right atrial pressure, PASP, PAWP, and NT-proBNP concentration greater than their median values, and left ventricular ejection fraction, cardiac output, and cardiac index less than their median values. In multivariate analyses, however, only NT-proBNP concentration remained an independent predictor of all-cause mortality. Both NT-proBNP concentration and PAWP were independent predictors of all-cause mortality and of the need for urgent cardiac transplantation. CONCLUSION Baseline data from routine right heart catheterization are of limited prognostic use in advanced heart failure. A baseline NT-proBNP concentration is a superior, non-invasive method of risk stratification in this era of measuring neurohormones.
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Affiliation(s)
- R S Gardner
- Department of Cardiology, University of Glasgow, Glasgow, UK.
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Abstract
Despite many advances in he diagnosis and treatment of DCM, it continues to be an important cause of cardiovascular morbidity and mortality in large-breed dogs. In the coming years, it is hoped and anticipated tht further discoveries will be made in the areas of etiology, therapy, and assessment of prognosis, ultimately with a view to having a greater impact on the clinical management of these cases.
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Affiliation(s)
- Michael R O'Grady
- Department of Clinical Studies, University of Guelph, Guelph, Ontario, Canada.
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49
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Goldberg A, Hammerman H, Petcherski S, Zdorovyak A, Yalonetsky S, Kapeliovich M, Agmon Y, Markiewicz W, Aronson D. Prognostic importance of hyponatremia in acute ST-elevation myocardial infarction. Am J Med 2004; 117:242-8. [PMID: 15308433 DOI: 10.1016/j.amjmed.2004.03.022] [Citation(s) in RCA: 58] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/12/2003] [Revised: 03/09/2004] [Accepted: 03/09/2004] [Indexed: 10/26/2022]
Abstract
PURPOSE To determine the prevalence and prognostic implications of hyponatremia in the setting of acute ST-elevation myocardial infarction. METHODS The study sample consisted of 1047 consecutive patients presenting with acute ST-elevation myocardial infarction. Plasma sodium concentrations were obtained on admission and at 24, 48, and 72 hours thereafter. Infarct size was determined by echocardiographic examination that was performed on day 2 or 3 of hospitalization. RESULTS Hyponatremia, defined as a plasma sodium level <135 mmol/L (<135 mEq/L), was present on admission in 131 patients (12.5%) and developed during the first 72 hours of hospitalization in 208 patients (19.9%). Plasma sodium levels decreased to < or = 130 mmol/L in 45 patients (4.3%). In a multivariate logistic regression analysis, hyponatremia was independently associated with 30-day mortality. The risk of 30-day mortality associated with hyponatremia on admission (odds ratio [OR] = 2.0; 95% confidence interval [CI]: 1.0 to 3.9; P = 0.04) was similar to that of hyponatremia developing after admission (OR = 2.4; 95% CI: 1.5 to 4.2; P = 0.002). The risk of 30-day mortality increased with the severity of hyponatremia, with an odds ratio of 2.1 in patients with sodium levels between 130 and 134 mmol/L (95% CI: 1.2 to 3.5; P = 0.007) and 3.4 in those with levels <130 mmol/L (95% CI: 1.5 to 7.8; P = 0.002). CONCLUSION Hyponatremia on admission or early development of hyponatremia in patients with acute ST-elevation myocardial infarction is an independent predictor of 30-day mortality, and prognosis worsens with the severity of hyponatremia. Further studies are required to determine if plasma sodium levels may serve as a simple marker to identify patients at high risk.
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Cabell CH, Trichon BH, Velazquez EJ, Dumesnil JG, Anstrom KJ, Ryan T, Miller AB, Belkin RN, Cropp AB, O'Connor CM, Jollis JG. Importance of echocardiography in patients with severe nonischemic heart failure: the second Prospective Randomized Amlodipine Survival Evaluation (PRAISE-2) echocardiographic study. Am Heart J 2004; 147:151-7. [PMID: 14691434 DOI: 10.1016/j.ahj.2003.07.010] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/20/2023]
Abstract
BACKGROUND Echocardiography is used commonly in clinical practice when caring for patients with heart failure. It is unknown whether the presence of certain findings provides an incremental ability to predict survival beyond the use of baseline clinical findings alone. The second PRAISE-2 echocardiographic study was prospectively designed to identify echocardiographic predictors of survival among patients with nonischemic cardiomyopathy and heart failure and to determine if components of the echocardiographic examination add prognostic information to baseline demographic and clinical information. METHODS One hundred patients participated in the second Prospective Randomized Amlodipine Survival Evaluation Study (PRAISE-2) echocardiographic study; of these, 93 had full and interpretable echocardiographic examinations. Cox proportional hazards modeling was used to assess the relation between various characteristics and survival as well as to assess the incremental prognostic information gained by echocardiography beyond the clinical examination. RESULTS Seven of 10 routine echocardiographic measures were significantly associated with death. These included mitral regurgitation (hazard ratio [HR], 2.31; 95% CI, 1.02, 5.27), left ventricular ejection fraction <20% (HR, 2.59; 95% CI, 1.14, 5.88), restrictive left ventricular filling pattern (HR, 2.37; 95% CI, 1.05, 5.32), and peak D velocity (HR, 1.62; 95% CI, 0.38, 0.87). The only statistically significant clinical predictor of survival was dyspnea at rest. The addition any of several echocardiographic parameters to baseline clinical information significantly improved the ability to predict survival. CONCLUSIONS Several readily available echocardiographic parameters are predictive of death and when added to clinical examination findings significantly improve the ability to determine prognosis among patients with nonischemic cardiomyopathy and heart failure.
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