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Ghio S, Traversi E, Maestri R, Camporotondo R, Caporotondi A, Caprino A, Fasolino A, Guazzotti G, Scelsi L, Turco A, La Rovere MT. Sodium nitroprusside infusion in patients with advanced heart failure. Vascul Pharmacol 2024; 156:107395. [PMID: 38964495 DOI: 10.1016/j.vph.2024.107395] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2024] [Revised: 06/01/2024] [Accepted: 06/16/2024] [Indexed: 07/06/2024]
Abstract
AIMS Advanced heart failure (AdvHF) poses significant treatment challenges, particularly when mechanical circulatory support or transplant options are unavailable, highlighting a gap in evidence-based medical management. The aim of this study was to evaluate the safety and effectiveness of sodium nitroprusside infusion (SNP) for enhancing systemic and renal perfusion in patients with AdvHF, with or without concomitant inotropic support. METHODS AND RESULTS We retrospectively analyzed the medical records of 406 patients with AdvHF admitted between October 2014 and September 2018 who received nocturnal SNP infusions for at least one week. In 55 patients with symptomatic hypotension or signs of peripheral hypoperfusion (differential systemic BP < 15 mmHg), continuous dobutamine infusion was added. In a subset of 155 patients who required multiple hospitalizations (median 3), data from the last hospitalization were used. No symptomatic hypotension leading to discontinuation of SNP (mean dose: 0.5 ± 0.1 μg/kg/min) was reported. Patients showed a significant increase in differential systemic blood pressure after infusion (29.2 ± 8.1 to 36.8 ± 11.6 mmHg, p < 0.001) independent of dobutamine use. Administration of SNP and dobutamine resulted in greater weight loss compared to SNP alone (-5.33 ± 7.02 vs -3.32 ± 4.0 kg, p < 0.003), but it was also associated with a significant increase in creatinine levels compared to SNP alone (+0.24 ± 0.87 vs +0.02 ± 0.43, p = 0.005). CONCLUSIONS The results show that SNP is a safe therapeutic choice in AdvHF patients with or without concomitant inotropic support and highlight the potential efficacy of nitroprusside in improving systemic and renal perfusion in these advanced patients.
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Affiliation(s)
- Stefano Ghio
- Division of Cardiology, Fondazione IRCCS Policlinico S.Matteo, Pavia, Italy.
| | - Egidio Traversi
- Department of Cardiac Rehabilitation, Istituti Clinici Scientifici Maugeri IRCCS, Montescano, Pavia, Italy
| | - Roberto Maestri
- Department of Cardiac Rehabilitation, Istituti Clinici Scientifici Maugeri IRCCS, Montescano, Pavia, Italy
| | - Rita Camporotondo
- Division of Cardiology, Fondazione IRCCS Policlinico S.Matteo, Pavia, Italy
| | - Angelo Caporotondi
- Department of Cardiac Rehabilitation, Istituti Clinici Scientifici Maugeri IRCCS, Montescano, Pavia, Italy
| | - Alessandra Caprino
- Department of Cardiac Rehabilitation, Istituti Clinici Scientifici Maugeri IRCCS, Montescano, Pavia, Italy
| | | | - Giampaolo Guazzotti
- Department of Cardiac Rehabilitation, Istituti Clinici Scientifici Maugeri IRCCS, Montescano, Pavia, Italy
| | - Laura Scelsi
- Division of Cardiology, Fondazione IRCCS Policlinico S.Matteo, Pavia, Italy
| | - Annalisa Turco
- Division of Cardiology, Fondazione IRCCS Policlinico S.Matteo, Pavia, Italy
| | - Maria Teresa La Rovere
- Department of Cardiac Rehabilitation, Istituti Clinici Scientifici Maugeri IRCCS, Montescano, Pavia, Italy
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Zhang X, Wang Z, Zhang L, Zhao X, Han Y. Comparative Effectiveness and Safety of Intermittent, Repeated, or Continuous Use of Levosimendan, Milrinone, or Dobutamine in Patients With Advanced Heart Failure: A Network and Single-Arm Meta-analysis. J Cardiovasc Pharmacol 2024; 84:92-100. [PMID: 38547524 DOI: 10.1097/fjc.0000000000001561] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/23/2023] [Accepted: 02/19/2024] [Indexed: 07/07/2024]
Abstract
ABSTRACT The aim of this study was to synthesize the available evidence regarding differences in the long-term safety and efficacy of intermittent, repeated, or continuous palliative inotropic therapy among patients with advanced heart failure. We systematically searched the PubMed, Embase, and Cochrane Library electronic databases, with a cutoff date of November 23, 2023, for studies reporting outcomes in adult patients with advanced heart failure treated with intermittent, repeated, or continuous levosimendan, milrinone, or dobutamine. Forty-one studies (18 randomized controlled trials and 23 cohort studies) comprising 5137 patients met the inclusion criteria. The results of the network meta-analysis of randomized controlled trials showed that levosimendan had significant advantages over milrinone or dobutamine in reducing mortality and improving left ventricular ejection fraction. A single-arm meta-analysis also indicated that levosimendan had the lowest mortality and significantly improved B-type brain natriuretic peptide and left ventricular ejection fraction. Regarding safety, hypotension events were observed more frequently in the levosimendan and milrinone groups. However, the current evidence is limited by the heterogeneity and relatively small sample size of the studies.
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Affiliation(s)
- Xue Zhang
- Department of Clinical Pharmacy, The First Affiliated Hospital of Shandong First Medical University & Shandong Provincial Qianfoshan Hospital, Shandong Engineering and Technology Research Center for Pediatric Drug Development, Shandong Medicine and Health Key Laboratory of Clinical Pharmacy, Jinan, Shandong Province, People's Republic of China ; and
| | - Zhongsu Wang
- Department of Cardiology, The First Affiliated Hospital of Shandong First Medical University & Shandong Provincial Qianfoshan Hospital, Shandong Medicine and Health Key Laboratory of Cardiac Electrophysiology and Arrhythmia, Jinan, Shandong Province, People's Republic of China
| | - Le Zhang
- Department of Clinical Pharmacy, The First Affiliated Hospital of Shandong First Medical University & Shandong Provincial Qianfoshan Hospital, Shandong Engineering and Technology Research Center for Pediatric Drug Development, Shandong Medicine and Health Key Laboratory of Clinical Pharmacy, Jinan, Shandong Province, People's Republic of China ; and
| | - Xia Zhao
- Department of Clinical Pharmacy, The First Affiliated Hospital of Shandong First Medical University & Shandong Provincial Qianfoshan Hospital, Shandong Engineering and Technology Research Center for Pediatric Drug Development, Shandong Medicine and Health Key Laboratory of Clinical Pharmacy, Jinan, Shandong Province, People's Republic of China ; and
| | - Yi Han
- Department of Clinical Pharmacy, The First Affiliated Hospital of Shandong First Medical University & Shandong Provincial Qianfoshan Hospital, Shandong Engineering and Technology Research Center for Pediatric Drug Development, Shandong Medicine and Health Key Laboratory of Clinical Pharmacy, Jinan, Shandong Province, People's Republic of China ; and
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3
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Ghio S, Mandurino-Mirizzi A, La Rovere MT, Traversi E, Lombardi C, Scelsi L, Senni M, Iacovoni A. Sodium nitroprusside for advanced heart failure. A metanalysis of literature data. Vascul Pharmacol 2023; 148:107140. [PMID: 36563732 DOI: 10.1016/j.vph.2022.107140] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2022] [Revised: 12/03/2022] [Accepted: 12/17/2022] [Indexed: 12/24/2022]
Abstract
Advanced heart failure (HF) is associated with a very poor prognosis and places a big burden on health-care services. The gold standard treatment, i.e. long-term mechanical circulatory support or heart transplantation, is precluded in many patients but observational studies suggest that the use of SNP might be associated with favourable long-term clinical outcomes. We performed a metanalysis of published studies that compared sodium nitroprusside (SNP) with optimal medical therapy to examine the safety and efficacy of SNP as part of the treatment regimen of patients hospitalized for advanced heart failure (HF). We searched PUBMED, EMBASE and WEB OF SCIENCE for studies that compared SNP with optimal medical therapy in advanced HF on July 2022. After screening 700 full-text articles, data from two original articles were included in a combined analysis. The analysis demonstrated a 66% reduction in the odds of death in advanced HF patients treated with SNP. The results show the potential importance of the inclusion of SNP in the treatment regimen of patients hospitalized because of advanced HF and underlines that controlled, randomized studies are still required in this condition.
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Affiliation(s)
- S Ghio
- Division of Cardiology, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy.
| | | | - M T La Rovere
- Department of Cardiac Rehabilitation, IRCCS Istituti Clinici Scientifici Maugeri, Montescano, Pavia, Italy
| | - E Traversi
- Department of Cardiac Rehabilitation, IRCCS Istituti Clinici Scientifici Maugeri, Montescano, Pavia, Italy
| | - C Lombardi
- Department of Medical and Surgical Specialties, Radiological Sciences and Public Health, University of Brescia, Italy
| | - L Scelsi
- Division of Cardiology, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy
| | - M Senni
- Division of Cardiology, ASST Papa Giovanni XXIII, Bergamo, Italy
| | - A Iacovoni
- Division of Cardiology, ASST Papa Giovanni XXIII, Bergamo, Italy
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4
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Buttà C, Roberto M, Tuttolomondo A, Petrantoni R, Miceli G, Zappia L, Pinto A. Old and New Drugs for Treatment of Advanced Heart Failure. Curr Pharm Des 2019; 26:1571-1583. [PMID: 31878852 DOI: 10.2174/1381612826666191226165402] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2019] [Accepted: 12/23/2019] [Indexed: 01/10/2023]
Abstract
BACKGROUND Advanced heart failure (HF) is a progressive disease with high mortality and limited medical therapeutic options. Long-term mechanical circulatory support and heart transplantation remain goldstandard treatments for these patients; however, access to these therapies is limited by the advanced age and multiple comorbidities of affected patients, as well as by the limited number of organs available. METHODS Traditional and new drugs available for the treatment of advanced HF have been researched. RESULTS To date, the cornerstone for the treatment of patients with advanced HF remains water restriction, intravenous loop diuretic therapy and inotropic support. However, many patients with advanced HF experience loop diuretics resistance and alternative therapeutic strategies to overcome this problem have been developed, including sequential nephron blockade or use of the hypertonic saline solution in combination with high-doses of furosemide. As classic inotropes augment myocardial oxygen consumption, new promising drugs have been introduced, including levosimendan, istaroxime and omecamtiv mecarbil. However, pharmacological agents still remain mainly short-term or palliative options in patients with acute decompensation or excluded from mechanical therapy. CONCLUSION Traditional drugs, especially when administered in combination, and new medicaments represent important therapeutic options in advanced HF. However, their impact on prognosis remains unclear. Large trials are necessary to clarify their therapeutic potential and prognostic role in these fragile patients.
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Affiliation(s)
- Carmelo Buttà
- Unità Operativa Complessa, Cardiologia, Dipartimento di Medicina Clinica e Sperimentale, Università degli Studi di Messina, Messina, Italy
| | - Marco Roberto
- Servizio di Cardiologia, Cardiocentro Ticino Lugano, Lugano, Switzerland
| | - Antonino Tuttolomondo
- Unità Operativa Complessa, Medicina Interna e con Stroke Care, Dipartimento di Promozione della Salute, Materno-infantile, Medicina Interna e Specialistica di Eccellenza, Università degli Studi di Palermo, Palermo, Italy
| | - Rossella Petrantoni
- Pronto Soccorso, Fondazione Istituto G. Giglio di Cefalù, 90015 Cefalù PA, Italy
| | - Giuseppe Miceli
- Unità Operativa Complessa, Medicina Interna e con Stroke Care, Dipartimento di Promozione della Salute, Materno-infantile, Medicina Interna e Specialistica di Eccellenza, Università degli Studi di Palermo, Palermo, Italy
| | - Luca Zappia
- Unità Operativa Complessa, Cardiologia, Dipartimento di Medicina Clinica e Sperimentale, Università degli Studi di Messina, Messina, Italy
| | - Antonio Pinto
- Unità Operativa Complessa, Medicina Interna e con Stroke Care, Dipartimento di Promozione della Salute, Materno-infantile, Medicina Interna e Specialistica di Eccellenza, Università degli Studi di Palermo, Palermo, Italy
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5
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Guo X, Zhu C, Liu X, Ge Y, Jiang X, Zhao W. Hyperoside protects against heart failure-induced liver fibrosis in rats. Acta Histochem 2019; 121:804-811. [PMID: 31353051 DOI: 10.1016/j.acthis.2019.07.005] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2019] [Revised: 06/18/2019] [Accepted: 07/14/2019] [Indexed: 12/16/2022]
Abstract
Heart failure (HF) is an end-stage of various serious cardiovascular diseases, which causes liver injury. Hyperoside has been reported to exert protective effect on liver injury and fibrosis. However, the role and related mechanisms of hyperoside in HF-induced liver fibrosis are still unclear. In the current study, we established a model of HF via aortocaval fistula (ACF) in rats in vivo. Hyperoside treatment in ACF rats increased cardiac output, the maximum peak rate of rise/fall in left ventricular pressure (+dP/dt, -dP/dt) and LV ejection fraction (LVEF), decreased LV end-systolic pressure (LVESP), LV end-diastolic pressure (LVEDP) and LV end-systolic volume (LVESV), and reduced heart weight/body weight ratio in a dose-dependent manner. Moreover, hyperoside could attenuate liver fibrosis and injury in ACF rats, as evidenced by reduction of fibrosis area and hydroxyproline content, amelioration of edema and degeneration of liver cell vacuoles, and inhibition of alanine aminotransferase (ALT), aspartate aminotransferase (AST) and alkaline phosphatase (ALP) levels. Further, α-smooth-muscle actin (α-SMA), collagen I, profibrotic factor-connective tissue growth factor (CTGF), matrix metalloproteinase-2 (MMP2) and MMP9 levels were down-regulated in hyperoside-treated ACF rats. Additionally, hyperoside inhibited the activation of TGF-β1/Smad pathway. Finally, we confirmed that hyperoside suppressed TGF-β1-mediated hepatic stellate cell activation in vitro. Collectively, hyperoside showed a suppressive role in HF-induced liver fibrosis and injury.
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6
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Amiya E, Taya M. Is Exercise Training Appropriate for Patients With Advanced Heart Failure Receiving Continuous Inotropic Infusion? A Review. CLINICAL MEDICINE INSIGHTS-CARDIOLOGY 2018; 12:1179546817751438. [PMID: 29326534 PMCID: PMC5757424 DOI: 10.1177/1179546817751438] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/18/2017] [Accepted: 12/07/2017] [Indexed: 12/18/2022]
Abstract
Exercise-based rehabilitation programs have been reported to have beneficial effects for patients with heart failure. However, there is little evidence about whether this is the case in patients with more severe heart failure. In particular, there is a question in the clinical setting whether patients with advanced heart failure and continuous inotropic infusion should be prescribed exercise training. In contrast, many studies conclude that prolonged immobility associated with heart failure profoundly impairs physical function and promotes muscle wasting that could further hasten the course of heart failure. By contrast, exercise training has various effects not only in improving exercise capacity but also on vascular function, skeletal muscle, and autonomic balance. In this review, we summarize the effectiveness and discuss methods of exercise training in patients with advanced heart failure receiving continuous inotropic agents such as dobutamine.
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Affiliation(s)
- Eisuke Amiya
- Department of Cardiovascular Medicine, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Masanobu Taya
- Department of Cardiovascular Medicine, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan.,Department of Rehabilitation Medicine, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
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7
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Pölzl G, Altenberger J, Baholli L, Beltrán P, Borbély A, Comin-Colet J, Delgado JF, Fedele F, Fontana A, Fruhwald F, Giamouzis G, Giannakoulas G, Garcia-González MJ, Gustafsson F, Kaikkonen K, Kivikko M, Kubica J, von Lewinski D, Löfman I, Malfatto G, Manito N, Martínez-Sellés M, Masip J, Merkely B, Morandi F, Mølgaard H, Oliva F, Pantev E, Papp Z, Perna GP, Pfister R, Piazza V, Bover R, Rangel-Sousa D, Recio-Mayoral A, Reinecke A, Rieth A, Sarapohja T, Schmidt G, Seidel M, Störk S, Vrtovec B, Wikström G, Yerly P, Pollesello P. Repetitive use of levosimendan in advanced heart failure: need for stronger evidence in a field in dire need of a useful therapy. Int J Cardiol 2017; 243:389-395. [PMID: 28571618 DOI: 10.1016/j.ijcard.2017.05.081] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/16/2017] [Revised: 05/15/2017] [Accepted: 05/20/2017] [Indexed: 10/19/2022]
Abstract
Patients in the latest stages of heart failure are severely compromised, with poor quality of life and frequent hospitalizations. Heart transplantation and left ventricular assist device implantation are viable options only for a minority, and intermittent or continuous infusions of positive inotropes may be needed as a bridge therapy or as a symptomatic approach. In these settings, levosimendan has potential advantages over conventional inotropes (catecholamines and phosphodiesterase inhibitors), such as sustained effects after initial infusion, synergy with beta-blockers, and no increase in oxygen consumption. Levosimendan has been suggested as a treatment that reduces re-hospitalization and improves quality of life. However, previous clinical studies of intermittent infusions of levosimendan were not powered to show statistical significance on key outcome parameters. A panel of 45 expert clinicians from 12 European countries met in Rome on November 24-25, 2016 to review the literature and envision an appropriately designed clinical trial addressing these needs. In the earlier FIGHT trial (daily subcutaneous injection of liraglutide in heart failure patients with reduced ejection fraction) a composite Global Rank Score was used as primary end-point where death, re-hospitalization, and change in N-terminal-prohormone-brain natriuretic peptide level were considered in a hierarchical order. In the present study, we tested the same end-point post hoc in the PERSIST and LEVOREP trials on oral and repeated i.v. levosimendan, respectively, and demonstrated superiority of levosimendan treatment vs placebo. The use of the same composite end-point in a properly powered study on repetitive levosimendan in advanced heart failure is strongly advocated.
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Affiliation(s)
| | | | | | | | - Attila Borbély
- Division of Clinical Physiology, Faculty of Medicine, University of Debrecen, Debrecen, Hungary
| | | | | | | | | | | | - Gregory Giamouzis
- University of Thessaly, Larissa University Hospital, Larissa, Greece
| | | | | | | | | | | | - Jacek Kubica
- Collegium Medicum Nicolaus Copernicus University, Bydgoszcz, Poland
| | | | - Ida Löfman
- Karolinska Univ Sjukhus Huddinge, Huddinge, Sweden
| | | | | | | | | | - Bela Merkely
- Heart and Vascular Center, Semmelweis University, Budapest, Hungary
| | | | | | | | | | - Zoltán Papp
- Division of Clinical Physiology, Faculty of Medicine, University of Debrecen, Debrecen, Hungary
| | - Gian Piero Perna
- Dipartimento di Scienze Cardiologiche Medico-Chirurgiche, Ospedali Riuniti, Ancona, Italy
| | - Roman Pfister
- Klinik III fuer Innere Medizin, Herzzentrum der Universität zu Köln, Germany
| | - Vito Piazza
- Azienda ospedaliera San Camillo-Forlanini, Rome, Italy
| | | | | | | | | | | | | | | | - Mirko Seidel
- Klinik für innere Medizin, Unfallkrankenhaus Berlin, Berlin, Germany
| | - Stefan Störk
- Comprehensive Heart Failure Center, University and University Hospital, Würzburg, Germany
| | | | - Gerhard Wikström
- Institute of Medical Sciences, Uppsala University, Uppsala, Sweden
| | - Patrik Yerly
- Centre Hospitalier Universitaire Vaudois CHUV, Lausanne, Switzerland
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8
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Nieminen MS, Dickstein K, Fonseca C, Serrano JM, Parissis J, Fedele F, Wikström G, Agostoni P, Atar S, Baholli L, Brito D, Colet JC, Édes I, Gómez Mesa JE, Gorjup V, Garza EH, González Juanatey JR, Karanovic N, Karavidas A, Katsytadze I, Kivikko M, Matskeplishvili S, Merkely B, Morandi F, Novoa A, Oliva F, Ostadal P, Pereira-Barretto A, Pollesello P, Rudiger A, Schwinger RHG, Wieser M, Yavelov I, Zymliński R. The patient perspective: Quality of life in advanced heart failure with frequent hospitalisations. Int J Cardiol 2015; 191:256-64. [PMID: 25981363 DOI: 10.1016/j.ijcard.2015.04.235] [Citation(s) in RCA: 108] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/01/2015] [Accepted: 04/30/2015] [Indexed: 12/27/2022]
Abstract
End of life is an unfortunate but inevitable phase of the heart failure patients' journey. It is often preceded by a stage in the progression of heart failure defined as advanced heart failure, and characterised by poor quality of life and frequent hospitalisations. In clinical practice, the efficacy of treatments for advanced heart failure is often assessed by parameters such as clinical status, haemodynamics, neurohormonal status, and echo/MRI indices. From the patients' perspective, however, quality-of-life-related parameters, such as functional capacity, exercise performance, psychological status, and frequency of re-hospitalisations, are more significant. The effects of therapies and interventions on these parameters are, however, underrepresented in clinical trials targeted to assess advanced heart failure treatment efficacy, and data are overall scarce. This is possibly due to a non-universal definition of the quality-of-life-related endpoints, and to the difficult standardisation of the data collection. These uncertainties also lead to difficulties in handling trade-off decisions between quality of life and survival by patients, families and healthcare providers. A panel of 34 experts in the field of cardiology and intensive cardiac care from 21 countries around the world convened for reviewing the existing data on quality-of-life in patients with advanced heart failure, discussing and reaching a consensus on the validity and significance of quality-of-life assessment methods. Gaps in routine care and research, which should be addressed, were identified. Finally, published data on the effects of current i.v. vasoactive therapies such as inotropes, inodilators, and vasodilators on quality-of-life in advanced heart failure patients were analysed.
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Affiliation(s)
| | | | - Cândida Fonseca
- S. Francisco Xavier Hospital, CHLO, NOVA Medical School, Faculdade de Ciências Médicas, Universidade Nova de Lisboa, Portugal
| | - Jose Magaña Serrano
- División de Educación en Salud, UMAE Hospital de Cardiología Centro Médico Nacional Siglo XXI, Instituto Mexicano del Seguro Social, Mexico
| | - John Parissis
- Second University Cardiology Clinic, Attiko Teaching Hospital, Athens, Greece
| | - Francesco Fedele
- Department of Cardiovascular, Respiratory, Nephrology and Geriatric Science, University of Rome, Italy
| | | | | | - Shaul Atar
- Department of Cardiology, Galilee Medical Center, Nahariya, Israel
| | - Loant Baholli
- Department of Intensive Care, Klinikum Dortmund, Germany
| | - Dulce Brito
- Cardiology Department, Hospital Universitario de Santa Maria, Lisbon, Portugal
| | | | - István Édes
- Department of Cardiology, University of Debrecen, Hungary
| | | | - Vojka Gorjup
- Department of Intensive Internal Medicine, University Medical Center Ljubljana, Slovenia
| | - Eduardo Herrera Garza
- Heart Failure, Heart Transplant Department, Centro Médico Zambrano Hellion, Heart Failure Clinic Unidad Médica de Alta Especialidad, Hospital de Cardiología No. 34, IMSS Monterrey Nuevo León, Mexico
| | | | - Nenad Karanovic
- Clinical Department of Anaesthesiology and Intensive Care, University Hospital of Split, Croatia
| | - Apostolos Karavidas
- Heart Failure Clinic & Echo Lab, Gennimatas General Hospital of Athens, Greece
| | - Igor Katsytadze
- Cardiology Intensive Care Unit, O. Bogomolets National Medical University, Kiev, Ukraine
| | | | | | - Béla Merkely
- Heart and Vascular Center, Semmelweis University, Budapest, Hungary
| | - Fabrizio Morandi
- Department of Cardiovascular Science, University of Insubria, Circolo Hospital and Macchi Foundation, Varese, Italy
| | | | - Fabrizio Oliva
- Department of Cardiology, Niguarda Ca'Granda Hospital, Milan, Italy
| | - Petr Ostadal
- Department of Cardiology, Cardiovascular Center, Na Homolce Hospital, Prague, Czech Republic
| | | | | | - Alain Rudiger
- Institute of Anaesthesiology, University Hospital Zurich, Switzerland
| | - Robert H G Schwinger
- Department of Internal Medicine, Kliniken Nordoberpfalz, Weiden, Germany; Teaching Hospital of the University of Regensburg, Germany
| | - Manfred Wieser
- Department of Internal Medicine 1, University Hospital Krems, Karl Landsteiner University of Health Sciences, Austria
| | - Igor Yavelov
- Scientific Research Institute of Physico-Chemical Medicine of the Federal Medico-Biological Agency of the Russian Federation, Moscow, Russia
| | - Robert Zymliński
- Department of Cardiology, Cardiology Intensive Care Unit, The 4th Military Hospital, Wroclaw, Poland
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9
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Hottinger DG, Beebe DS, Kozhimannil T, Prielipp RC, Belani KG. Sodium nitroprusside in 2014: A clinical concepts review. J Anaesthesiol Clin Pharmacol 2014; 30:462-71. [PMID: 25425768 PMCID: PMC4234779 DOI: 10.4103/0970-9185.142799] [Citation(s) in RCA: 110] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
Sodium nitroprusside has been used in clinical practice as an arterial and venous vasodilator for 40 years. This prodrug reacts with physiologic sulfhydryl groups to release nitric oxide, causing rapid vasodilation, and acutely lowering blood pressure. It is used clinically in cardiac surgery, hypertensive crises, heart failure, vascular surgery, pediatric surgery, and other acute hemodynamic applications. In some practices, newer agents have replaced nitroprusside, either because they are more effective or because they have a more favorable side-effect profile. However, valid and adequately-powered efficacy studies are sparse and do not identify a superior agent for all indications. The cyanide anion release concurrent with nitroprusside administration is associated with potential cyanide accumulation and severe toxicity. Agents to ameliorate the untoward effects of cyanide are limited by various problems in their practicality and effectiveness. A new orally bioavailable antidote is sodium sulfanegen, which shows promise in reversing this toxicity. The unique effectiveness of nitroprusside as a titratable agent capable of rapid blood pressure control will likely maintain its utilization in clinical practice for the foreseeable future. Additional research will refine and perhaps expand indications for nitroprusside, while parallel investigation continues to develop effective antidotes for cyanide poisoning.
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Affiliation(s)
- Daniel G Hottinger
- Department of Anesthesiology, University of Minnesota, Minneapolis, MN 55455, USA
| | - David S Beebe
- Department of Anesthesiology, University of Minnesota, Minneapolis, MN 55455, USA
| | - Thomas Kozhimannil
- Department of Anesthesiology, University of Minnesota, Minneapolis, MN 55455, USA
| | - Richard C Prielipp
- Department of Anesthesiology, University of Minnesota, Minneapolis, MN 55455, USA
| | - Kumar G Belani
- Department of Anesthesiology, University of Minnesota, Minneapolis, MN 55455, USA
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Abstract
Inotrope use is one of the most controversial topics in the management of heart failure. While the heart failure community utilizes them and recognizes the state of inotrope dependency, retrospective analyses and registry data have overwhelmingly suggested high mortality, which is logically to be expected given the advanced disease states of those requiring their use. Currently, there is a relative paucity of randomized control trials due to the ethical dilemma of creating control groups by withholding inotropes from patients who require them. Nonetheless, results of such trials have been mixed. Many were also performed with agents no longer in use, on patients without an indication for inotropes, or at a time before automatic cardio-defibrillators were recommended for primary prevention. Thus, their results may not be generalizable to current clinical practice. In this review, we discuss current indications for inotrope use, specifically dobutamine and milrinone, depicting their mechanisms of action, delineating their patterns of use in clinical practice, defining the state of inotrope dependency, and ultimately examining the literature to ascertain whether evidence is sufficient to support the current view that these agents increase mortality in patients with heart failure. Our conclusion is that the evidence is insufficient to link inotropes and increased mortality in low output heart failure.
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Effect of levosimendan on the short-term clinical course of patients with acutely decompensated heart failure. JACC-HEART FAILURE 2013; 1:103-11. [PMID: 24621834 DOI: 10.1016/j.jchf.2012.12.004] [Citation(s) in RCA: 279] [Impact Index Per Article: 25.4] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Received: 12/05/2012] [Revised: 12/21/2012] [Accepted: 12/28/2012] [Indexed: 12/25/2022]
Abstract
BACKGROUND This study evaluated the efficacy and safety of levosimendan, a positive inotropic drug with vasodilator effects, given intravenously to patients with acutely decompensated heart failure (ADHF). METHODS We performed 2 sequential trials, the first to develop a new measure of efficacy in 100 patients, and the second to use this measure to evaluate levosimendan in an additional 600 patients. Patients admitted with ADHF received placebo or intravenous levosimendan for 24 h in addition to standard treatment. The primary endpoint was a composite that evaluated changes in clinical status during the first 5 days after randomization. RESULTS In the 600-patient trial, more levosimendan than placebo patients (58 vs. 44) were improved at all 3 pre-specified time points (6 h, 24 h, and 5 days), whereas fewer levosimendan patients (58 vs. 82) experienced clinical worsening (p = 0.015 for the difference between the groups). These differences were apparent, despite more frequent intensification of adjunctive therapy in the placebo group (79 vs. 45 patients). Improvements in patient self-assessment and declines in B-type natriuretic peptide levels with levosimendan persisted for 5 days and were associated with reduced length of stay (p = 0.009). Similar findings were present in the 100-patient pilot trial. Levosimendan was associated with more frequent hypotension and cardiac arrhythmias during the infusion period and a numerically higher risk of death across the 2 trials (49 of 350 on a regimen of levosimendan vs. 40 of 350 on a regimen of placebo at 90 days, p = 0.29). CONCLUSIONS In patients with ADHF, intravenous levosimendan provided rapid and durable symptomatic relief. As dosed in this trial, levosimendan was associated with an increased risk of adverse cardiovascular events. (Evaluation of Intravenous Levosimendan Efficacy in the Short Term Treatment of Decompensated Chronic Heart Failure; NCT00048425).
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12
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13
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Deutsch-österreichische S3-Leitlinie „Infarktbedingter kardiogener Schock – Diagnose, Monitoring und Therapie“. ACTA ACUST UNITED AC 2011. [DOI: 10.1007/s00390-011-0284-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
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14
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Opasich C, Cioffi G, Gualco A. Nitroprusside in decompensated heart failure: what should a clinician really know? Curr Heart Fail Rep 2009; 6:182-90. [PMID: 19723460 DOI: 10.1007/s11897-009-0026-4] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Sodium nitroprusside is an older intravenous vasodilator appropriate for acute hospital treatment of patients with congestive heart failure. It is a balanced arterial and venous vasodilator with a very short half-life, facilitating rapid titration. In general, it improves hemodynamic and clinical status by reducing systemic vascular resistance, left ventricular filling pressure, and increasing cardiac output. This review summarizes recently published literature and recent data regarding the use of this intravenous vasodilator in decompensated heart failure patients.
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Affiliation(s)
- Cristina Opasich
- Division of Cardiology, Salvatore Maugeri Foundation, Pavia, Italy.
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15
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Abstract
Recent guidelines by the Heart Failure Society of America have recommended consideration for use of nitroprusside, nitroglycerin, or nesiritide in addition to diuretics to achieve hemodynamic and symptomatic improvement. This article reviews the results of previous studies evaluating the pharmacologic and clinical effects and safety profiles of these drugs in patients with heart failure.
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Long KM, Kirby R. An update on cardiovascular adrenergic receptor physiology and potential pharmacological applications in veterinary critical care. J Vet Emerg Crit Care (San Antonio) 2008. [DOI: 10.1111/j.1476-4431.2007.00266.x] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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Kieback AG, Grohmann A, Baumann G, Felix SB. Haemodynamic effects of intravenous quinaprilat in comparison to sodium nitroprusside in patients with chronic heart failure. Int J Cardiol 2007; 121:102-4. [PMID: 17098309 DOI: 10.1016/j.ijcard.2006.08.040] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/20/2006] [Accepted: 08/04/2006] [Indexed: 10/23/2022]
Abstract
We compared the haemodynamic effects of intravenous boluses of the ACE inhibitor quinaprilat with an intravenous infusion of sodium nitroprusside in 23 patients with chronic heart failure (NYHA Class III or IV). At the highest drug doses, sodium nitroprusside significantly increased stroke volume index (+6.63 ml/m(2), p=0.045), whereas quinaprilat induced only a minor increase (+1.79 ml/m(2), n.s.).
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18
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Sackner-Bernstein JD. Management of diuretic-refractory, volume-overloaded patients with acutely decompensated heart failure. Curr Cardiol Rep 2005; 7:204-10. [PMID: 15865862 DOI: 10.1007/s11886-005-0078-3] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
Fluid overload is a common presentation for decompensated heart failure, yet management strategies are poorly defined because of relatively few randomized clinical trials that delineate an optimal strategy. Patients refractory to diuretic therapy may be considered for treatment with inotropes or vasodilators, and others may be considered for venovenous ultrafiltration. The rationale for use of each therapy is reviewed.
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Affiliation(s)
- Jonathan D Sackner-Bernstein
- Clinical Scholars Program, Division of Cardiology, 1st Floor Cohen, North Shore University Hospital, 300 Community Drive, Manhasset, NY 11030, USA.
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Effects of a single, 24-hour, low-dose intravenous dobutamine infusion on left ventricular myocardial performance index in congestive heart failure: A prospective, nonrandomized study. Curr Ther Res Clin Exp 2005; 66:35-44. [DOI: 10.1016/j.curtheres.2005.03.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/23/2004] [Indexed: 11/18/2022] Open
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20
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Strain WD. The use of recombinant human B-type natriuretic peptide (nesiritide) in the management of acute decompensated heart failure. Int J Clin Pract 2004; 58:1081-7. [PMID: 15605677 DOI: 10.1111/j.1368-5031.2004.00424.x] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Abstract
Nesiritide is a synthetic human B-type natriuretic factor that has a balanced arterial and venous dilator effect, with natriuretic, diuretic, anti-aldosterone and antisympathetic action. It was launched in the US for the treatment of acute decompensated heart failure (ADHF) in August 2001 and, recently, in Switzerland and Israel. It has been demonstrated to provide more rapid and sustained haemodynamic stabilisation than glyceryl trinitrate and significant symptomatic improvement vs. placebo at 3 h, and to be safer than dobutamine. The main side effects associated with nesiritide therapy are asymptomatic and symptomatic hypotension, which are treated with dose reduction. When compared to dobutamine, the increased acquisition costs of nesiritide are completely offset by reduced intensity of hospital admissions and reduced readmission rate at 3 weeks.
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Affiliation(s)
- W D Strain
- National Heart and Lung Institute, Faculty of Medicine, Imperial College London at St Mary's, Norfolk Place, London, UK.
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21
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Abstract
PURPOSE OF REVIEW The growing epidemic of systolic congestive heart failure mandates strategies to identify accurately people with high morbidity and mortality. Echocardiography remains the most widely available noninvasive tool for the assessment of cardiac structure, function, and hemodynamics. Clinical data paired with echocardiographic analysis in patients with systolic heart failure obtained from a variety of investigations have allowed for the evaluation of this modality as a prognostic tool. RECENT FINDINGS Detailed appraisal of the literature has revealed five distinct, easy-to-evaluate echocardiographic parameters that may assist clinicians to segregate high-risk patients. The presence of or the inability to modify a left ventricular ejection fraction less than 25%, impaired right ventricular function (assessed by any of four methods), left ventricular end-diastolic dimension greater than 6.5 to 7 cm, a restrictive mitral inflow, or pulmonary hypertension (peak tricuspid regurgitant velocity >2.5 m/s) should alert clinicians of patients with high morbidity (recurrent congestive heart failure admission, arrhythmia, impaired functional capacity) and mortality. Particularly important among these variables is the presence of a restrictive mitral inflow pattern. SUMMARY Detailed analysis of two-dimensional and Doppler data routinely obtained from echocardiograms has established prognostic implications among patients with systolic heart failure. Although prospective clinical trials are lacking, the use of echocardiography to segregate risk should be incorporated into current strategies to treat congestive heart failure and influence clinical listing for cardiac transplantation.
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Affiliation(s)
- Vinay Thohan
- DeBakey Heart Center, Winters Center for Heart Failure Research, Gene and Judy Campbell Laboratory for Cardiac Transplant Research, Baylor College of Medicine, and Methodist Hospital, Houston, Texas 77030, USA.
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Manito N, Kaplinsky EJ, Pujol R. Tratamiento inotrópico en la insuficiencia cardíaca: aspectos generales y resultados clínicos. Med Clin (Barc) 2004; 122:269-74. [PMID: 15012878 DOI: 10.1016/s0025-7753(04)75320-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
Classic inotropic agents such as beta-adrenergic agonists and phosphodiesterase III inhibitors have beneficial but transitory hemodynamic effects in patients with acute and chronic heart failure. In this context, the available data suggest that long term inotropic therapy has a negative impact on morbidity and mortality in patients with heart failure. For this reason, these agents are mainly used for the treatment of refractory episodes of decompensation and they are also used as a "bridge" (transplant, revascularization, recovery) or as a palliative measure. We present a revision of the general aspects of inotropes including main published clinical trials and some findings of its combined use with beta blockers. Furthermore, we describe a promising and differential therapeutic approach represented by calcium sensitizer agents (levosimendan).
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Affiliation(s)
- Nicolás Manito
- Unidad de Insuficiencia Cardíaca y Trasplante Cardíaco, Hospital de Bellvitge, L'Hospitalet de Llobregat, Barcelona, Spain.
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Paolocci N, Katori T, Champion HC, St John ME, Miranda KM, Fukuto JM, Wink DA, Kass DA. Positive inotropic and lusitropic effects of HNO/NO- in failing hearts: independence from beta-adrenergic signaling. Proc Natl Acad Sci U S A 2003; 100:5537-42. [PMID: 12704230 PMCID: PMC154380 DOI: 10.1073/pnas.0937302100] [Citation(s) in RCA: 257] [Impact Index Per Article: 12.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/14/2023] Open
Abstract
Nitroxyl anion (HNONO(-)), the one-electron reduced form of nitric oxide (NO), induces positive cardiac inotropy and selective venodilation in the normal in vivo circulation. Here we tested whether HNO/NO(-) augments systolic and diastolic function of failing hearts, and whether contrary to NO/nitrates such modulation enhances rather than blunts beta-adrenergic stimulation and is accompanied by increased plasma calcitonin gene-related peptide (CGRP). HNO/NO(-) generated by Angelis' salt (AS) was infused (10 microg/kg per min, i.v.) to conscious dogs with cardiac failure induced by chronic tachycardia pacing. AS nearly doubled contractility, enhanced relaxation, and lowered cardiac preload and afterload (all P < 0.001) without altering plasma cGMP. This contrasted to modest systolic depression induced by an NO donor diethylamine(DEA)NO or nitroglycerin (NTG). Cardiotropic changes from AS were similar in failing hearts as in controls despite depressed beta-adrenergic and calcium signaling in the former. Inotropic effects of AS were additive to dobutamine, whereas DEA/NO blunted beta-stimulation and NTG was neutral. Administration of propranolol to nonfailing hearts fully blocked isoproterenol stimulation but had minimal effect on AS inotropy and enhanced lusitropy. Arterial plasma CGRP rose 3-fold with AS but was unaltered by DEA/NO or NTG, supporting a proposed role of this peptide to HNO/NO(-) cardiotropic action. Thus, HNO/NO(-) has positive inotropic and lusitropic action, which unlike NO/nitrates is independent and additive to beta-adrenergic stimulation and stimulates CGRP release. This suggests potential of HNO/NO(-) donors for the treatment of heart failure.
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Affiliation(s)
- Nazareno Paolocci
- Division of Cardiology, Department of Medicine, The Johns Hopkins Medical Institutions, Baltimore, MD 21287, USA
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Chatterjee K, De Marco T. Role of nonglycosidic inotropic agents: indications, ethics, and limitations. Med Clin North Am 2003; 87:391-418. [PMID: 12693731 DOI: 10.1016/s0025-7125(02)00185-2] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/17/2023]
Abstract
Nonglycosidic inotropic agents have been used for the short-term management of low output states and hypotension complicating acute myocardial infarction for several years. Without adequate reperfusion of the ischemic myocardium, inotropic agents are seldom effective in producing sustained hemodynamic responses. Furthermore, the potential exists for enhancement of ischemia and extension of myocardial necrosis. Thus, inotropic and vasopressors therapy should be regarded as temporary supportive treatment in patients with acute coronary syndrome and should be discontinued as soon as feasible. Parenteral sympathomimetic agents, usually dobutamine, and phosphodiesterase inhibitors, usually milrinone, are used for the management of exacerbations of chronic systolic heart failure. Although hemodynamics, and occasionally clinical status, improve, such therapy is associated with increased mortality and can potentially hasten a patient's demise. Nonparenteral sympathomimetics, such as ibopamine, phosphodiesterase-III inhibitors, such as milrinone and enoximone, calcium-sensitizing agents, such as pimobendan, and other novel inotropic agents, such as vesnarinone, all increase mortality of patients with chronic heart failure. Furthermore, newer noninotropic agents, such as B-natriuretic peptide, have been introduced for treatment of decompensated heart failure. New nonpharmacologic devices, such as biventricular pacing, are available for the treatment of advanced heart failure. Thus, indications for the use of presently available nonglycosidic inotropic agents are limited and should be considered only for short-term therapy or when no other treatment is available.
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Affiliation(s)
- Kanu Chatterjee
- Department of Medicine, University of California at San Francisco, Chatterjee Center for Cardiac Research, Moffit-Long Hospital, San Francisco, CA 94143, USA.
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Greenberg B, Borghi C, Perrone S. Pharmacotherapeutic approaches for decompensated heart failure: a role for the calcium sensitiser, levosimendan? Eur J Heart Fail 2003; 5:13-21. [PMID: 12559210 DOI: 10.1016/s1388-9842(02)00118-6] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Although no universal definition exists, decompensated heart failure may be regarded as either a worsening of chronic heart failure or new-onset heart failure precipitated by an acute incident. Haemodynamic management of patients hospitalised with decompensated heart failure may include the administration of diuretics, vasodilators and positive inotropic agents. Until recently, these latter agents constituted the only drug class to produce a direct increase in stroke volume via enhanced myocardial contractility. However, despite their short-term benefits, the clinical utility of inotropic agents is compromised by their potentially deleterious effects on calcium handling and oxygen consumption, resulting in an increased risk of serious ventricular arrhythmias and death. In contrast, calcium sensitisers enhance cardiac performance without affecting calcium movement and, therefore, are potentially associated with a reduced risk of rhythmic disturbances. These agents constitute a heterogeneous group of compounds with different affinities for calcium sensitisation. Levosimendan is a potent calcium sensitiser with vasodilating properties that has been shown to provide symptomatic and haemodynamic improvement with no increase in oxygen consumption. Calcium sensitisation is therefore emerging as a promising treatment approach in this challenging therapeutic area.
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Affiliation(s)
- Barry Greenberg
- Department of Medicine, University of California School of Medicine, San Diego, CA 92103, USA.
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Mehra MR, Uber PA. Emergence of Laplace therapeutics: declaring an end to end-stage heart failure. CONGESTIVE HEART FAILURE (GREENWICH, CONN.) 2002; 8:228-31, 234. [PMID: 12147947 DOI: 10.1111/j.1527-5299.2002.01417.x] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
A large number of chronic heart failure patients escape from the benefits of neurohormonal blockade only to transit into a discouragingly miserable state of what the physician often refers to as end-stage heart failure. Conceptually, the designation of end-stage as a description of a clinical scenario implies pessimism concerning recourse to a therapeutic avenue. A variety of surgical therapeutic techniques that take advantage of the law of Laplace, designed to effectively restore the cardiac shape from a spherical, mechanically inefficient pump to a more elliptical, structurally sound organ are now being employed. Additionally, the field of mechanical device implantation is surging ahead at a rapid pace. The weight of evidence regarding mechanical unloading using assist devices suggests that hemodynamic restoration is accompanied by regression of cellular hypertrophy, normalization of the neuroendocrine axis, improved expression of contractile proteins, enhanced cellular respiratory control, and decreases in markers of apoptosis and cellular stress. Thus, these lines of data point toward discarding the notion of end-stage heart failure. We are at a new crossroad in our quest to tackle chronic heart failure. It is our contention that the use of antiremodeling strategies, including device approaches, will soon signal the end of end-stage heart failure.
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Affiliation(s)
- Mandeep R Mehra
- Ochsner Cardiomyopathy and Heart Transplantation Center, Ochsner Clinic Foundation, New Orleans, LA 70121, USA.
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Pharmacoepidemiology and drug safety. Pharmacoepidemiol Drug Saf 2002; 11:255-70. [PMID: 12051126 DOI: 10.1002/pds.659] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
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