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Yang W, Zhou YJ, Fu Y, Qin J, Qin S, Chen XM, Guo JC, Wang DZ, Zhan H, Li J, He JY, Hua Q. Efficacy and Safety of Intravenous Urapidil for Older Hypertensive Patients with Acute Heart Failure: A Multicenter Randomized Controlled Trial. Yonsei Med J 2017; 58:105-113. [PMID: 27873502 PMCID: PMC5122625 DOI: 10.3349/ymj.2017.58.1.105] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/31/2016] [Revised: 07/05/2016] [Accepted: 07/08/2016] [Indexed: 01/06/2023] Open
Abstract
PURPOSE Urapidil is putatively effective for patients with hypertension and acute heart failure, although randomized controlled trials thereon are lacking. We investigated the efficacy and safety of intravenous urapidil relative to that of nitroglycerin in older patients with hypertension and heart failure in a randomized controlled trial. MATERIALS AND METHODS Patients (>60 y) with hypertension and heart failure were randomly assigned to receive intravenous urapidil (n=89) or nitroglycerin (n=91) for 7 days. Hemodynamic parameters, cardiac function, and safety outcomes were compared. RESULTS Patients in the urapidil group had significantly lower mean systolic blood pressure (110.1±6.5 mm Hg) than those given nitroglycerin (126.4±8.1 mm Hg, p=0.022), without changes in heart rate. Urapidil was associated with improved cardiac function as reflected by lower N terminal-pro B type natriuretic peptide after 7 days (3311.4±546.1 ng/mL vs. 4879.1±325.7 ng/mL, p=0.027) and improved left ventricular ejection fraction (62.2±3.4% vs. 51.0±2.4%, p=0.032). Patients given urapidil had fewer associated adverse events, specifically headache (p=0.025) and tachycardia (p=0.004). The one-month rehospitalization and all-cause mortality rates were similar. CONCLUSION Intravenous administration of urapidil, compared with nitroglycerin, was associated with better control of blood pressure and preserved cardiac function, as well as fewer adverse events, for elderly patients with hypertension and acute heart failure.
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Affiliation(s)
- Wei Yang
- Department of Geriatrics, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Yu Jie Zhou
- Department of Cardiology, An Zhen Hospital affiliated with Capital Medical University, Beijing, China
| | - Yan Fu
- Fu Yan Emergency Department, Tong Ren Hospital affiliated with Capital Medical University, Beijing, China
| | - Jian Qin
- Department of Cardiology, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Shu Qin
- Department of Cardiology, First Hospital affiliated with Chongqing University, Chongqing, China
| | - Xiao Min Chen
- Department of Cardiology, Ningbo First Hospital, Ningbo, China
| | - Jin Cheng Guo
- Department of Cardiology, Luhe Hospital of Beijing Tongzhou District, Beijing, China
| | - De Zhao Wang
- Department of Cardiology, Mentougou District Hospital of Beijing City, Beijing, China
| | - Hong Zhan
- Emergency Department, First Hospital affiliated with Sun Yat-sen University, Guangzhou, China
| | - Jing Li
- Department of Cardiology, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Jing Yu He
- Emergency Department, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Qi Hua
- Department of Cardiology, Xuanwu Hospital, Capital Medical University, Beijing, China.
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Yang W, Zhou YJ, Fu Y, Qin J, Tan S, Chen XM, Guo JC, Wang DEZ, Zhan H, Guan W, Xu YW, He JY, Li J, Hua QI. Therapeutic effects of intravenous urapidil in elderly patients with hypertension and acute decompensated heart failure: A pilot clinical trial. Exp Ther Med 2016; 12:115-122. [PMID: 27347026 PMCID: PMC4906984 DOI: 10.3892/etm.2016.3302] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2015] [Accepted: 04/05/2016] [Indexed: 11/15/2022] Open
Abstract
Urapidil has been proposed to be an effective vasodilator for the treatment of acute decompensated heart failure (ADHF); however, its effect on cardiac function, as compared with that of nitroglycerin, in elderly patients with hypertension and ADHF has yet to be determined. In the present study, a multicenter, open-label clinical trial was performed, in which 120 elderly patients with hypertension and ADHF were randomly assigned to the treatment (50–400 µg/min intravenous urapidil) or control group (5–40 µg/min intravenous nitroglycerin). The dosages of the medications were adjusted according to the blood pressure of the patients. The systolic and diastolic blood pressure, heart rate and serum level of N-terminal pro B-type natriuretic peptide (NT-proBNP) were evaluated at hospital admission and at days 1, 2, 3 and 7 after treatment. In addition, the left ventricular function was assessed by measuring the left ventricular ejection fraction (LVEF) and left ventricular end-diastolic volume at hospital admission and at days 2 and 7 after treatment. The results indicated that intravenous administration of urapidil and nitroglycerin were effective in lowering the blood pressure and heart rate within 7 days, with no significant differences observed between the two groups (P>0.05). By contrast, greater reduction in the serum NT-proBNP level (2,410.4±546.1 vs. 4,234.1±876.4 pg/ml; P<0.05) and greater improvement in the LVEF (55.3±3.4 vs. 45.2±2.4%; P<0.05) were observed in the urapidil-treated group, as compared with the nitroglycerin-treated group. No adverse events were reported during the treatment period in the two groups. The clinical outcomes at 6 months following discharge were evaluated and were not found to be significantly different between the two groups. In conclusion, the present results of the present study suggested that urapidil was as effective as nitroglycerin in controlling blood pressure and heart rate and was more effective in improving cardiac systolic function in elderly patients with hypertension and ADHF.
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Affiliation(s)
- Wei Yang
- Department of Geriatrics, Xuan Wu Hospital, Capital Medical University, Beijing 100053, P.R. China
| | - Yu-Jie Zhou
- Department of Cardiology, An Zhen Hospital Affiliated to Capital Medical University, Beijing 100029, P.R. China
| | - Yan Fu
- Emergency Department, Tong Ren Hospital Affiliated to Capital Medical University, Beijing 100005, P.R. China
| | - Jian Qin
- Department of Cardiology, Xuan Wu Hospital, Capital Medical University, Beijing 100053, P.R. China
| | - Shu Tan
- Department of Cardiology, First Affiliated Hospital, Chongqing Medical University, Chongqing 400016, P.R. China
| | - Xiao-Min Chen
- Department of Cardiology, Ningbo First Hospital, Ningbo, Zhejiang 315010, P.R. China
| | - Jin-Cheng Guo
- Department of Cardiology, Luhe Hospital, Affiliated to Capital Medial University, Beijing 101100, P.R. China
| | - DE-Zhao Wang
- Department of Cardiology, Mentougou District Hospital of Beijing City, Beijing 102300, P.R. China
| | - Hong Zhan
- Emergency Department, The First Affiliated Hospital of Sun Yat-sen University, Guangzhou, Guangdong 510080, P.R. China
| | - Wei Guan
- Department of Cardiology, Heilongjiang Provincial Hospital, Harbin, Heilongjiang 150030, P.R. China
| | - Ya-Wei Xu
- Department of Cardiology, Shanghai Tenth People's Hospital, Tongji University School of Medicine, Shanghai 200072, P.R. China
| | - Jing-Yu He
- Department of Cardiology, Xuan Wu Hospital, Capital Medical University, Beijing 100053, P.R. China
| | - Jing Li
- Department of Cardiology, Xuan Wu Hospital, Capital Medical University, Beijing 100053, P.R. China
| | - Q I Hua
- Department of Cardiology, Xuan Wu Hospital, Capital Medical University, Beijing 100053, P.R. China
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Yilmaz B, Zuckerman WA, Lee TM, Beddows KD, Gilmore LA, Singh RK, Richmond ME, Chen JM, Addonizio LJ. Left ventricular assist device to avoid heart-lung transplant in an adolescent with dilated cardiomyopathy and severely elevated pulmonary vascular resistance. Pediatr Transplant 2013; 17:E113-6. [PMID: 23710645 PMCID: PMC3773308 DOI: 10.1111/petr.12096] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 04/16/2013] [Indexed: 01/12/2023]
Abstract
Orthotopic heart transplantation remains the definitive treatment of choice for patients with end-stage heart failure; however, elevated PVRI is a reported risk factor for mortality after heart transplant and, when severely elevated, is considered an absolute contraindication. Use of a ventricular assist device has been proposed as one treatment for reducing pulmonary vascular resistance index in potential heart transplant candidates refractory to medical vasodilator therapies. We report on a teenage patient with dilated cardiomyopathy and severely elevated PVRI, unresponsive to pulmonary vasodilator therapy, who underwent left ventricular assist device implantation to safely allow for aggressive pulmonary vasodilator therapy and to decrease PVRI. The resulting dramatic improvement in PVRI in a relatively short period of time allowed for successful heart transplantation, avoiding the need for heart-lung transplant.
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Affiliation(s)
- Betul Yilmaz
- Division of Cardiology, Department of Pediatrics, Morgan Stanley Children's Hospital, Columbia University College of Physicians and Surgeons, New York, NY 10032, USA.
| | - Warren A. Zuckerman
- Division of Cardiology, Department of Pediatrics, Morgan Stanley Children's Hospital, Columbia University College of Physicians and Surgeons, New York, NY
| | - Teresa M. Lee
- Division of Cardiology, Department of Pediatrics, Morgan Stanley Children's Hospital, Columbia University College of Physicians and Surgeons, New York, NY
| | - Kimberly D. Beddows
- Division of Cardiology, Department of Pediatrics, Morgan Stanley Children's Hospital, Columbia University College of Physicians and Surgeons, New York, NY
| | - Lisa A. Gilmore
- Division of Cardiology, Department of Pediatrics, Morgan Stanley Children's Hospital, Columbia University College of Physicians and Surgeons, New York, NY
| | - Rakesh K. Singh
- Division of Cardiology, Department of Pediatrics, Morgan Stanley Children's Hospital, Columbia University College of Physicians and Surgeons, New York, NY
| | - Marc E. Richmond
- Division of Cardiology, Department of Pediatrics, Morgan Stanley Children's Hospital, Columbia University College of Physicians and Surgeons, New York, NY
| | - Jonathan M. Chen
- Department of Cardiothoracic Surgery, Weill Medical College of Cornell University, New York, NY
| | - Linda J. Addonizio
- Division of Cardiology, Department of Pediatrics, Morgan Stanley Children's Hospital, Columbia University College of Physicians and Surgeons, New York, NY
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Nair PK, Kormos RL, Teuteberg JJ, Mathier MA, Bermudez CA, Toyoda Y, Dew MA, Simon MA. Pulsatile left ventricular assist device support as a bridge to decision in patients with end-stage heart failure complicated by pulmonary hypertension. J Heart Lung Transplant 2010; 29:201-8. [PMID: 20113910 DOI: 10.1016/j.healun.2009.09.013] [Citation(s) in RCA: 92] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2009] [Revised: 09/28/2009] [Accepted: 09/30/2009] [Indexed: 10/19/2022] Open
Abstract
BACKGROUND Severe pulmonary hypertension (PH) in heart failure (HF) is a risk factor for adverse outcomes after heart transplantation (HTx). Left ventricular assist devices (LVADs) improve pulmonary hemodynamics, but our understanding of the degree of improvement and the effect on outcomes is still evolving. METHODS We reviewed invasive pulmonary hemodynamics from 58 consecutive patients receiving LVAD support as a bridge to HTx from 1996 to 2003. The primary outcome was change in baseline transpulmonary gradient (TPG) during LVAD support and after HTx/recovery. The secondary outcome was post-HTx survival. RESULTS All patients (age, 49 +/- 14 years, 79% male, 40% ischemic) received a pulsatile LVAD (median support, 97 days; interquartile range [IQR], 31-222). Hemodynamic measurements were obtained at baseline (median, 1 day; IQR, 1-3), during early (median, 1 day; IQR, 0-4) and late (median, 75 days; IQR, 24-186) LVAD support, and after HTx/recovery (median, 28 days; IQR, 17-40). Improvement in TPG occurred throughout LVAD support and was sustained after HTx/recovery. Levels of TPG reductions in patients with a baseline TPG in the highest quartile (14.1-26.0 mm Hg) were 8.6 +/- 3.5 vs 6.5 +/- 3.1 mm Hg in the lowest quartile (2.0-7.7 mm Hg) during LVAD support (p = 0.102), with 90% vs 100% 30-day post-HTx survival (P = 0.113). CONCLUSION Pulmonary hemodynamics and post-HTx survival were similar after pulsatile LVAD support in patients with and without pre-implant PH. LVAD support may be a useful strategy to reverse PH in carefully selected patients, thus improving candidacy for HTx.
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Affiliation(s)
- Pradeep K Nair
- Cardiovascular Institute, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
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Zimpfer D, Zrunek P, Roethy W, Czerny M, Schima H, Huber L, Grimm M, Rajek A, Wolner E, Wieselthaler G. Left ventricular assist devices decrease fixed pulmonary hypertension in cardiac transplant candidates. J Thorac Cardiovasc Surg 2007; 133:689-95. [PMID: 17320566 DOI: 10.1016/j.jtcvs.2006.08.104] [Citation(s) in RCA: 138] [Impact Index Per Article: 8.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/21/2006] [Revised: 08/03/2006] [Accepted: 08/10/2006] [Indexed: 12/01/2022]
Abstract
OBJECTIVE Fixed pulmonary hypertension is a contraindication for cardiac transplantation because of the increased risk of donor heart failure. We sought to determine whether left ventricular assist devices improve fixed pulmonary hypertension in cardiac transplant candidates to enable safe cardiac transplantation. METHODS Thirty-five consecutive cardiac transplant candidates (age 56 +/- 6 years, 88.5% were men) with fixed pulmonary hypertension (5.1 +/- 2.6 Wood units) resistant to medical treatment received a left ventricular assist device as a bridge to transplantation. Three left ventricular assist device systems were used (pulsatile blood flow: Novacor [World Heart Inc, Oakland, Calif] n = 8; continuous blood flow: MicroMed DeBakey [MicroMed Technology Inc, Houston, Tex] n = 24, DuraHeart [Terumo Heart Inc, Ann Arbor, Mich] n = 3). Right-sided heart catheter data were obtained before left ventricular assist device implantation at 3-day and 6-week follow-ups. Clinical data and complications were recorded. RESULTS Before left ventricular assist device implantation, the pulmonary vascular resistance was 5.1 +/- 2.8 Wood units. Values were comparable in patients receiving pulsatile (5.1 +/- 3.4 Wood units) or continuous blood flow left ventricular assist devices (5.1 +/- 2.7 Wood units, P = .976). Left ventricular assist device implantation decreased pulmonary vascular resistance at 3-day (2.9 +/- 1.3 Wood units, P < .0001) and 6-week (2.0 +/- 0.8 Wood units, P < .0001) follow-ups compared with before implantation. This effect was independent of the type of left ventricular assist device system used (3-day follow-up: pulsatile flow: 3.2 +/- 1.3 Wood units vs continuous flow: 2.7 +/- 1.2 Wood units; P = .310 and 6-week follow-up: pulsatile flow: 1.9 +/- 0.9 Wood units vs continuous flow: 2.1 +/- 0.8 Wood units; P = .905). Twenty-four patients had successful bridges to transplantation (69%, mean time on left ventricular assist device 210 +/- 83 days), and 11 patients died before transplantation (31%, mean time on left ventricular assist device 67 +/- 30 days). The 1-year survival after transplantation was 95%. CONCLUSION Left ventricular assist devices decrease fixed pulmonary hypertension in cardiac transplant candidates and allow patients to overcome a contraindication for cardiac transplantation. Therefore, left ventricular assist devices should be considered in all cardiac transplant candidates with fixed pulmonary hypertension.
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Affiliation(s)
- Daniel Zimpfer
- Department of Cardiothoracic Surgery, Medical University of Vienna, Wahringer Guertel, Vienna, Austria.
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Klotz S, Deng MC, Hanafy D, Schmid C, Stypmann J, Schmidt C, Hammel D, Scheld HH. Reversible pulmonary hypertension in heart transplant candidates-pretransplant evaluation and outcome after orthotopic heart transplantation. Eur J Heart Fail 2003; 5:645-53. [PMID: 14607204 DOI: 10.1016/s1388-9842(03)00059-x] [Citation(s) in RCA: 40] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/26/2022] Open
Abstract
BACKGROUND Heart transplantation is the most effective treatment for well-selected patients with endstage heart failure. Unfortunately, transplant candidates with pulmonary hypertension (PHT) are often not considered for heart transplantation. This study was performed to assess the value of prostaglandin E(1) (PG-E(1)) for reduction of PHT and to predict the postoperative outcome, compared to patients without PHT. PATIENTS AND METHODS We studied a group of 151 consecutive heart transplant candidates using right heart catheterization. In patients with PHT (pulmonary vascular resistance, PVR> or =2.5 Wood-Units (WU) and/or transpulmonary gradient (TPG)> or =12 mmHg) a short-term treatment protocol with PG-E(1) was performed, to achieve PVR<2.5 WU and TPG<12 mmHg. RESULTS 61 patients (40%) had PHT according to our criteria. Reduction of PHT was successful in 71% of patients (n=43), of these, 18 patients underwent cardiac transplantation and the 1-year mortality rate was 22% (n=4). The 1-year mortality rate in transplanted patients without PHT was 14% (n=3). There was no statistical difference in survival between the PHT and the non-PHT group. Outcome in patients without heart transplantation was similar in both groups, except for patients with non-reducible PHT (1-year mortality 50%). CONCLUSIONS Our study demonstrates the efficacy and safety of PG-E(1) in lowering PHT in heart transplant candidates, as well as the need for aggressive evaluation and treatment in these patients. Patients with reversible PHT have comparable post-transplant outcomes and no tendency to higher acute right ventricular failure.
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Affiliation(s)
- Stefan Klotz
- Department of Thoracic and Cardiovascular Surgery, University Hospital Münster, Albert-Schweitzer-Street 33, 48149 Münster, Germany.
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Abstract
PURPOSE OF REVIEW Disorders of the pulmonary circulation might develop as a primary disease process of the pulmonary vascular bed or, more often, as the acute or chronic consequence of pulmonary or cardiac pathologies. For the anaesthesiologist and intensivist it is particularly interesting to gain insight into the regulation of the pulmonary circulation since pulmonary hypertension and concomitant right heart failure contribute to high perioperative mortality rates in patients at risk, especially after cardiac surgery. Therefore, modulation of the pulmonary circulation may be a life-saving therapy in patients suffering from acute or chronic pulmonary circulatory disorders. Furthermore, routinely performed intra-operative interventions such as the use of volatile anaesthetics or cardiopulmonary bypass systems may have relevant side effects on the pulmonary circulation. RECENT FINDINGS This review focuses on new insights into the modulation of pulmonary circulation during general anaesthesia with volatile anaesthetics and anaesthesiological management during cardiopulmonary surgery. Recent publications in the field of cardiopulmonary bypass surgery, one-lung ventilation and heart and lung transplantation are discussed. Furthermore, the role of conventional and experimental therapeutic strategies to modulate pulmonary circulation in intensive care medicine is reviewed. SUMMARY Despite the performance of a large number of clinical and experimental studies, the pathophysiology of pulmonary circulatory disorders is not completely understood. Therefore, any new therapy has to be carefully evaluated as a therapeutic option. Several formerly experimental therapeutic interventions such as inhaled vasodilators, however, appear to have found their way into clinical practice for selected indications.
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Affiliation(s)
- Rolf Dembinski
- Department of Anaesthesiology, University Hospital Aachen, Germany.
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