bluuebunny/crossref_metadata_2025 huggingface dataset:
The Acute Hemodynamic Effect of IV Nitroglycerin and Dipyridamole in Patients With Pulmonary Arterial Hypertension: Comparison With IV Epoprostenol
Authors: Sulica Roxana , Dinh Howard V. , Dunsky Kevin , Fuster Valentin , Poon Michael
Published: February 2007

Nitroglycerin and dipyridamole are two commonly available and well tolerated vasoactive medications. Their acute hemo‐dynamic effects in patients with pulmonary arterial hypertension are not well defined in the current literature. The authors retrospectively analyzed the acute hemodynamic effects of IV nitroglycerin, dipyridamole, and epoprostenol in 59 patients with pulmonary arterial hypertension as determined by changes from baseline in systemic and pulmonary hemodynamic parameters. Statistical analysis was performed using the independent sample t test. A p value <0.05 was considered significant. Nitroglycerin is predominantly a vasodilator of the pulmonary vasculature with moderate systemic vasodilator effect, while dipyridamole is primarily a positive inotropic agent. Epoprostenol is a potent vasodilator of both pulmonary and systemic vessels and a strong positive inotropic agent. Nitroglycerin and dipyridamole may be useful in the acute management of pulmonary arterial hypertension.
Utility of Impedance Cardiography to Improve Physician Estimation of Hemodynamic Parameters in the Emergency Department
Authors: Neath Sean‐Xavier , Lazio Lucia , Guss David A.
Published: February 2007

Emergency physicians must often make assessments of complex hemodynamic parameters. To assess the utility of impedance cardiography (ICG) in the emergency department, the authors examined treating physicians' abilities to assess stroke volume (SV), cardiac output (CO), and systemic vascular resistance (SVR) by comparing the clinicians' estimates of these values to ICG measurements. Treating physicians were asked to estimate the SV, CO, and SVR of acutely ill patients as being low, normal, or high. ICG measurements of SV, CO, and SVR were also categorized as low, normal, or high. Physician estimates were compared with ICG measures for concordance. Changes of therapy initiated as a result of discordance between physician's estimates and ICG measurements were recorded. The treating physician assessments and ICG hemodynamic measurements were concordant in 62 of 101 (62%) cases for SV (kappa=0.068), in 53 of 101 (53%) cases for CO (p=0.125), and in 50 of 101 (50%) measurements for SVR (p=0.148). The low concordance suggests that treating physicians did not consistently estimate SV, CO, and SVR accurately. ICG provides noninvasive hemodynamic measurements of SV, CO, and SVR that offer clinical utility and potential value in the emergency department.
Novel Therapies for Heart Failure: Vasopressin and Selective Aldosterone Antagonists
Authors: Kamath Sandeep A. , Laskar S. Raja , Yancy Clyde W.
Published: February 2007

Despite favorable improvements in mortality, heart failure (HF) remains a problematic illness due to the ever‐present burden of hospitalization. Clearly, novel treatment strategies are needed. This review focuses on two newer pharmacologic targets: arginine vasopressin and aldosterone. Arginine vasopressin receptor antagonists will most likely serve as an adjunct to or replacement of standard diuretic therapy in selected patients. The safety and efficacy of chronic therapy with oral arginine vasopressin receptor antagonists in large groups of congestive HF patients is currently under investigation. Aldosterone antagonism is emerging as a treatment of severe congestive HF. Recent large‐scale clinical trials using aldosterone antagonists have proven that those with HF or left ventricular dysfunction postmyocardial infarction derive a survival benefit from aldosterone antagonism. Whether aldosterone antagonism should be prescribed in all patients with HF is unclear; however, in carefully selected and managed patients, aldosterone antagonism is helpful.
Anemia, Chronic Heart Failure, and the Impact of Male vs. Female Gender
Authors: Fox Marshal T. , Jorde Ulrich P.
Published: February 2007

Anemia is common in subjects with chronic heart failure, and correction of anemia improves quality of life and exercise capacity in both men and women. The definition of anemia is sex‐specific, but enrollment criteria of studies examining the effects of recombinant human erythropoietin in chronic heart failure to date have not taken sex into account. Indeed, it is unknown whether sex‐specific differences of hemoglobin values observed in normal individuals are maintained in subjects with chronic disease and volume overload states. Given the significant treatment implications for sex‐specific differences in hemoglobin values, the authors analyzed data for 260 subjects consecutively admitted with decompensated chronic heart failure. In a multivariate regression analysis controlling for serum creatinine and age, female sex was independently associated with lower hemoglobin. When deciding upon initiation of treatment in this population, sex‐specific targets should be applied.
New Graduated Pressure Regimen for External Counterpulsation Reduces Mortality and Improves Outcomes in Congestive Heart Failure: A Report From the Cardiomedics External Counterpulsation Patient Registry
Authors: Vijayaraghavan Krishnaswami , Santora Lawrence , Kahn Joel , Abbott Norman , Torelli Julius , Vardi Gil
Published: February 2007

External counterpulsation (ECP) has been shown to increase exercise tolerance and reduce angina episodes, Canadian Cardiovascular Society Functional (CCSF) class, anginal medication usage, and hospitalizations in refractive CCSF class III and IV stable angina. However, the high pressures and resulting 1.5:1–2:1 peak diastolic to peak systolic pressure (D/S) ratios shown to be optimal in the treatment of angina can cause excessive preload and adverse effects in congestive heart failure (CHF) patients, particularly those with left ventricular ejection fractions <40%. Data were retrospectively analyzed from the Cardiomedics ECP Registry on 127 New York Heart Association (NYHA) class II—IV CHF patients (79.6% men; average age ± SD, 68.2±15.6 years), with a comorbidity of CCSF class III–IV refractive angina, who were serially treated with 35 hours of ECP (1 h/d, 5 d/wk for 7 weeks) at unconventionally low pressures and D/S ratios under a new graduated pressure regimen. The pressures and D/S ratios were gradually increased in stages over the 7‐week ECP regimen. The patients were divided into three groups based on the pressures applied and the resulting average D/S ratios (Low, Mid, and High). In the Low D/S ratio group (average D/S ratio 0.7:1), all‐cause mortality in the year following ECP treatment was only 1.85% (one of 54 patients), whereas over the same time period in the Mid D/S ratio group (average D/S ratio 1.08:1), all‐cause mortality was 7.69% (three of 39 patients) and in the High D/S ratio group (average D/S ratio 1.32:1), all‐cause mortality was 8.82% (three of 34 patients). For the Low, Mid, and High D/S ratio groups, respectively: 1) average left ventricular ejection fractions increased 23.0%, 20.1%, and 17.5%; 2) NYHA class declined 36.6%, 29.6%, and 29.6%; and 3) all‐cause hospitalizations, including terminal admissions, were reduced 85.7%, 82.6%, and 57.1% in the year following ECP therapy from the prior year. There were no adverse effects or withdrawals from the ECP therapy and no significant difference in sex‐based outcomes. Consequently, ECP applied at low pressures and average D/S ratios of 0.7:1 under the new graduated pressure regimen is safe and effective in the treatment of CHF and produces a significant reduction in mortality, compared with the 8.5% annualized mortality of the Multicenter Automatic Defibrillator Implantation Trial II (MADIT II) (N=1232) of NYHA class II–III CHF and the 12.2% annual mortality of the Comparison of Medical Therapy, Pacing, and Defibrillation in Heart Failure (COMPANION) study (N=595) of NYHA class III–IV CHF. Lower pressures improve patient comfort and may encourage more CHF patients to seek treatment. The reduction in hospitalizations should significantly reduce the cost of treating CHF.
The COMET Trial
Authors: Bristow Michael R. , Adams Kirkwood F. , Bauman Jerry L. , Feldman Arthur M. , Giles Thomas D. , Goldstein Sidney , Mann Douglas L. , Talbert Robert L.
Published: February 2007

A roundtable discussion by cardiac specialists and pharmacologists was convened on August 18, 2003, to discuss and critique the results of the Carvedilol or Metoprolol European Trial (COMET), which were recently published in The Lancet.1 Michael R. Bristow, MD, PhD, Head of the Division of Cardiology at the University of Colorado Health Sciences Center in Denver, CO, moderated the discussion. Panelists included Kirkwood F. Adams, Jr., MD, Associate Professor of Medicine and Radiology, University of North Carolina at Chapel Hill School of Medicine, Chapel Hill, NC; Jerry L. Bauman, PharmD, Professor of Pharmacy Practice and Medicine, University of Illinois at Chicago, Chicago, IL; Arthur M. Feldman, MD, PhD, Magee Professor of Medicine, Jefferson Medical College, Philadelphia, PA; Thomas D. Giles, MD, Professor of Medicine, Louisiana State University School of Medicine, New Orleans, LA; Sidney Goldstein, MD, Professor of Medicine, Case Western Reserve University, Detroit, MI; Douglas L. Mann, MD, Professor of Medicine, Winters Center for Heart Failure Research, Houston, TX; and Robert L. Talbert, PharmD, Professor of Pharmacy, University of Texas at Austin, Professor of Pharmacology and Medicine, University of Texas Health Science Center, San Antonio, TX.
Gender and Its Effect in Cardiovascular Pharmacotherapeutics: Recent Considerations
Authors: Sica Domenic A. , Wood Mark , Hess Michael
Published: February 2007

Gender differences in drug pharmacokinetics and pharmacodynamics have been recognized for some time. This issue has generally been ignored in clinical practice, despite there being ample evidence to suggest that gender can influence multiple aspects of pharmacokinetics. Gastric acid secretion, gastrointestinal blood flow, proportions of muscular and adipose tissue, the amount of drug‐binding proteins, gender‐specific changes in the available amount of P450 isozymes, physiologic and hormonal changes during the menstrual cycle, and differences in renal blood flow are several factors that may have some bearing on sex‐related differences in pharmacokinetics. Furthermore, female‐specific issues such as pregnancy, menopause, oral contraceptive use, and menstruation may independently influence drug metabolism and serve as confounders to the interpretation of gender differences in drug handling or effect. While gender‐related pharmacodynamic data are limited, evidence suggests that women are more prone to the development of torsade de pointes from proarrhythmic drugs such as quinidine or d‐sotalol and have an increased cardiovascular risk with the use of digoxin. The specific risk:benefit ratio for individual cardiovascular medications should be more routinely considered in the context of gender.
Brain Injury and Ventricular Dysfunction: Insights Into Reversible Heart Failure
Authors: Goel Radha , Johnson Frances , Mehra Mandeep R.
Published: February 2007

The unique syndrome of brain death is associated with cardiac dysfunction; however, if such a heart is removed from this environment and transplanted, the cardiac dysfunction often resolves. This scenario offers insight into the mechanisms of reversible forms of cardiac injury and suggests that treatment of the extra‐cardiac milieu by removing the initiating insult can often result in recovery. The mechanisms leading to reversible cardiac dysfunction are discussed in this review, with concentration on the implications of such injury in determining outcomes following transplantation.
Hyponatremia and Heart Failure—Pathophysiology and Implications
Authors: Sica Domenic A.
Published: February 2007

Fluid and electrolyte disturbances are a common feature of heart failure. Among the electrolyte disturbances that occur in heart failure, disorders of potassium and magnesium have traditionally received the most attention. Abnormalities involving either of these actions serve as risk factors for sudden cardiac death/arrhythmias. More recently, a growing appreciation has emerged for the importance of hyponatremia in the heart failure patient. Hyponatremia is multifactorial in origin, and its presence correlates with disease severity and outcome. There are few effective therapies for hyponatremia, and those that are available are not viewed as offering specific survival benefits per se. The recent availability of vasopressin receptor antagonists, however, offers a different approach to the management of this complex electrolyte disturbance, but one that is still evolving as to the scope of its clinical benefits.
BNP‐Guided Therapy Not Better Than Expert's Clinical Assessment for β‐Blocker Titration in Patients With Heart Failure
Authors: Beck‐da‐Silva Luís , de Bold Adolfo , Fraser Margaret , Williams Kathryn , Haddad Haissam
Published: February 2007

B‐type natriuretic peptide (BNP) is a cardiac neurohormone used as a noninvasive tool for diagnosing and monitoring heart failure. Beta blockers have beneficial effects in patients with heart failure as well as a direct effect on BNP plasma levels. The aim of this study is to compare the efficacy of a BNP‐guided approach vs. standard care on β‐blocker titration in heart failure patients. Forty‐one patients with heart failure were randomized into a clinical trial. Bisoprolol was started, and the dose was regularly up‐titrated. BNP was measured monthly. The clinical group had β‐blocker dosage increased according to standard care, whereas the BNP group had β‐blocker dosage up‐titrated according to plasma BNP levels plus standard care. The primary outcome was mean β‐blocker dose achieved after 3 months. BNP levels, left ventricular ejection fraction, clinical score, quality of life, and hospitalization were collected in all patients. BNP‐guided up‐titration of β blocker in ambulatory patients with heart failure did not result in higher doses of β blocker at the end of 3 months ± SD (5.9±4.3 mg vs. 4.4±3.4 mg, p=0.22). Left ventricular ejection fraction was significantly improved in both groups by 7.3% (95% confidence interval, 4.1%–10.4%; p<0.0001). A trend toward better quality of life was seen in the BNP group.
Acute Pulmonary Hypertension Secondary to Right Ventricular Pacing in a Patient With Sinus Node Dysfunction and Severe Ischemic Cardiomyopathy
Authors: Speziani Giancarlo H. , Jimenez Javier , Rechani Luis , Mallon Stephen , Interian Alberto , Myerburg Robert
Published: February 2007

Right ventricular pacing has been associated with worsening symptoms of heart failure in patients with cardiomyopathy. We describe a patient with severe ischemic cardiomyopathy and sinus node dysfunction who developed acute worsening of pulmonary hypertension immediately after right ventricular pacing.
Polycystic Ovary Syndrome and Heart Failure
Authors: Iyengar Srinivas , Schafer Michael , Haas Garrie
Published: February 2007

This is a case of a 21‐year‐old female with a history of polycystic ovary syndrome who was subsequently diagnosed with heart failure. The patient did not have a family history of heart failure, nor did the patient herself have evidence of ischemic or valvular heart disease or prior viral infection. The patient was found, upon further evaluation, to have significant obstructive sleep apnea, a condition that has been linked to the development and/or worsening of heart failure. Interestingly enough, recent evidence has revealed that patients with polycystic ovary syndrome have been found to have a predilection for developing obstructive sleep apnea, irrespective of body weight or habitus.
Prevalence of the Third and Fourth Heart Sound in Asymptomatic Adults
Authors: Collins Sean P. , Arand Patricia , Lindsell Christopher J. , Peacock W. Frank , Storrow Alan B.
Published: February 2007

The prevalence of abnormal diastolic heart sounds in asymptomatic adults has been the subject of great debate. The authors determined the prevalence of an electronically detected S3 and S4 in 1329 asymptomatic adults between the ages of 18 and 94. The authors also investigated the relationship between abnormal diastolic heart sounds, age, and electrocardiography. The overall prevalence of S3 was 10.0% (95% confidence interval [Cl], 8.1%–12.2%), S4 was 15.6% (95% Cl, 13.2%–18.2%), and both S3 and S4 were 3.5% (95% Cl, 2.4%–5.0%). Using multinomial logistic regression, increasing age was found to decrease the odds of an S3 being heard (odds ratio, 0.96; 95% Cl, 0.95–0.96) and increase the odds of an S4 being heard (odds ratio, 1.04; 95% Cl, 1.03–1.05). We conclude that the prevalence of an S3 is increased earlier in life, that an S4 is less common than previous studies suggest, and that its detection, even in the elderly, should not be ignored.
Diurnal Variation in QT Dispersion in Patients With Chronic Heart Failure
Authors: Kinoshita Osamu , Wakamatsu Masaomi , Tomita Takeshi , Aizawa Kazunori , Kasai Hiroki , Kumazaki Setsuo , Tsutsui Hiroshi , Koyama Jun , Yazaki Yoshikazu , Watanabe Noboru , Hongo Minoru , Ikeda Uichi
Published: February 2007

QT dispersion is defined as the difference in QT interval among the different leads of the standard 12‐lead electrocardiogram and reflects inhomogeneity of myocardial repolarization. Dispersion of repolarization is an important electrophysiologic feature that is considered fundamental for the initiation of ventricular fibrillation. However, no data exist regarding the diurnal variation of QT dispersion measured from simultaneous 12‐lead recording in chronic heart failure patients. The aim of this study was to identify diurnal variation in QT dispersion in patients with chronic heart failure. QT dispersion was measured in the 12‐lead standard electrocardiogram in 11 patients with chronic heart failure. QT dispersion in these patients was increased in the afternoon compared to the morning. It is concluded that QT dispersion has a clear diurnal variation in patients with chronic heart failure. These findings have potentially significant implications for therapy and prevention of sudden cardiac death in patients with chronic heart failure.
Prevalence of Symptomatic Diastolic Heart Failure in Patients Hospitalized With Cerebral or Peripheral Vascular Disease
Authors: Kelly Robert V. , Tan Walter A. , Cho Hyunsoon , Tudor Gail , Ohman E. Magnus , Struthers Allan D.
Published: February 2007

The authors sought to determine the prevalence of diastolic heart failure (DHF) in patients hospitalized with their first stroke, transient ischemic attack, or new onset of peripheral vascular disease. A total of 216 prospective consecutive stroke, transient ischemic attack, and peripheral vascular disease patients (vascular group) were identified at their first noncardiac presentation to a hospital and compared with 164 age‐matched control patients (nonvascular group). DHF was clinically defined as the presence of left ventricular ejection fraction ≥45% on echocardiography. DHF occurred in 40% and 73% of vascular and control patients, respectively, with symptomatic heart failure. Overall, it was found in 12% of vascular (10% of stroke/transient ischemic attack, 16% of peripheral vascular disease) and 11% of control patients. Advancing age and female gender were independently associated with the presence of DHF in vascular patients (p<0.05). DHF is found in a similar percentage of vascular and nonvascular patients. Symptomatic DHF is less common than systolic heart failure among vascular disease patients with heart failure. In contrast, symptomatic DHF is found in three times as many age‐matched control heart failure patients without clinical vascular disease.
Increased Cost Effectiveness With Nesiritide vs. Milrinone or Dobutamine in the Treatment of Acute Decompensated Heart Failure
Authors: Scroggins Nancy , Edwards Michelle , Delgado Reynolds
Published: February 2007

Despite recent advances in the treatment of patients with acute decompensated heart failure, the cost of treatment for such patients remains considerable. IV diuretics, vasodilators, and positive inotropic agents are commonly prescribed. A retrospective data analysis was conducted to determine the cost effectiveness of nesiritide compared with milrinone and dobutamine administered in a hospital setting during episodes of acute decompensated heart failure. Nesiritide‐treated patients demonstrated a significantly lower overall hospital length of stay, intensive care unit length of stay, and average cost per case compared with dobutamine or milrinone. Although the acquisition cost of nesiritide was higher than that of milrinone and dobutamine, nesiritide was a more cost‐effective treatment option for patients with acute decompensated heart failure in this study.
Increasing Self‐Management Skills in Heart Failure Patients: A Pilot Study
Authors: Flynn Kristin J. , Powell Lynda H. , Mendes de Leon Carlos F. , Muñoz Rocio , Eaton Claudia B. , Downs Diane L. , Silver Marc A. , Calvin James E.
Published: February 2007

Nonadherence to medical treatment among heart failure patients is high and results in frequent exacerbations and premature death. This treatment‐only pilot study examined whether a year‐long group‐based self‐management intervention is feasible and improves self‐management skills in patients with mild‐to‐moderate heart failure (ejection fraction ≤40% and New York Heart Association functional class I, II, or III). A total of 31 of 100 recruited patients (31%) agreed to participate. Twenty‐six (84%) completed the year‐long self‐management program. Compared with baseline, the intervention was associated with an increase in overall self‐efficacy in practicing self‐management skills (p<0.001) and in four of five specific self‐management skills. Patients and their group leaders also reported an increase in actual use of self‐management skills (p<0.001) and in several psychosocial outcomes. The success of this pilot study suggests the need for a randomized clinical trial to test the efficacy of group‐based self‐management training on medical outcomes.
Left Ventricular Assist Device Therapy for End‐Stage Congestive Heart Failure: From REMATCH to the Future
Authors: Smart Frank W. , Palanichamy Nanthini
Published: February 2007

Therapy for patients with end‐stage cardiomyopathy continues to evolve, but clearly it must now involve left ventricular assist device therapy as either bridge‐to‐transplantation or destination therapy. Patients who are selected for left ventricular assist device support must be able to undergo the surgical implantation procedure safely and avoid common complications such as right heart failure. Adequate patient selection is essential and can typically be accomplished using simple hemodynamic measures. As left ventricular assist device technology evolves, pulsatile devices will likely be replaced by their newer axial flow counterparts, which offer decided advantages. In the future, therapy for end‐stage heart failure will involve aggressive use of mechanical assist device therapy and, as more patients are supported with these devices and the technology improves, this will become a burgeoning field for cardiologists and cardiovascular surgeons.
Cardiac Resynchronization Therapy and Tools to Identify Responders
Authors: Miske Glen , Acevedo Celso , Goodlive Thomas W. , Brown C. Michael , Levine T. Barry
Published: February 2007

Heart failure is a major epidemic. Many people with heart failure struggle with refractory symptoms despite optimal medical therapy. Those with severe left ventricular dysfunction and ventricular conduction delay are at significant risk from either dying suddenly or dying from progression of their heart failure. Cardiac resynchronization therapy (CRT) improves hemodynamics and symptoms of heart failure and has recently been shown to improve survival. One problem facing the use of CRT is that 30% of patients fail to respond. The dominant theory is that QRS duration (electrical dyssynchrony) does not accurately reflect mechanical dyssynchrony. Echocardiographic tools have recently been developed that enable clinicians to assess the degree of mechanical dyssynchrony in patients being considered for CRT. These tools are able to predict with a significant amount of accuracy whether a patient will respond to CRT. This allows for a more refined approach to evaluating patients for CRT and optimizing the treatment of congestive heart failure.
Intrathoracic Impedance to Monitor Heart Failure Status: A Comparison of Two Methods in a Chronic Heart Failure Dog Model
Authors: Ganion Vincent , Rhodes Melissa , Stadler Robert W.
Published: February 2007

In patients with heart failure (HF), a convenient and accurate assessment of HF status could enhance titration of medications and possibly reduce hospitalizations for fluid overload. This study examined the feasibility of monitoring HF status by measuring intrathoracic impedance with either an implantable cardioverter‐defibrillator or a pacemaker. Six canines were each instrumented with four devices: two capable of measuring intrathoracic impedance between a right ventricular coil electrode and the device case, one custom pacemaker for inducing HF, and an implantable hemodynamic monitor to measure left ventricular end‐diastolic pressure as an assessment of HF status. High‐rate ventricular pacing for 3–7 weeks induced HF, followed by a 4‐week recovery period. During high‐rate pacing, left ventricular end‐diastolic pressure was inversely correlated with impedance measurements from both systems (median r=−0.66; range r=−0.38 to −0.81). During recovery, the inverse correlation between left ventricular end‐diastolic pressure and impedance was enhanced (median r=−0.88; range r=−0.58 to −0.95). The two types of impedance measurements were highly correlated (median r=−0.68 during pacing and r=−0.91 during recovery). These results suggest that various methods of measurement of intrathoracic impedance over time could be used to monitor HF status.
Is Functional Capacity Related to Left Atrial Contractile Function in Nonobstructive Hypertrophic Cardiomyopathy?
Authors: Shizukuda Yukitaka , Sachdev Vandana , Fananapazir Lameh , Tripodi Dorothy , Mohiddin Saidi A. , Arai Andrew E. , Waclawiw Myron A. , Plehn Jonathan F.
Published: February 2007

The mechanisms underlying reduced exercise capacity in patients with nonobstructive hypertrophic cardiomyopathy (NHCM) could include perturbations of ventricular relaxation, diastolic compliance, or compensatory atrial systolic function. We hypothesized that a loss of atrial contractility in NHCM patients leads to reduced functional capacity. To test this hypothesis, we compared resting noninvasive left atrial ejection phase indices in 49 consecutive patients with NHCM (ages 36±10 years; 41% female) and normal left ventricular ejection fraction (mean, 68%±8%) with objective metabolic exercise parameters. Left atrial active emptying fraction, ejection force, and kinetic energy failed to predict exercise capacity. Only left atrial total and active emptying volumes correlated weakly with minute volume/CO2 production slope (r=0.31 and r=0.33; p<0.05 for both). Furthermore, when subjects were stratified by New York Heart Association symptomatology, exercise parameters—but not atrial contractility—differed between groups. These data, obtained at rest, fail to suggest that NHCM‐related heart failure symptoms are due to an atrial myopathy.
Benefits of Comprehensive Inpatient Education and Discharge Planning Combined With Outpatient Support in Elderly Patients With Congestive Heart Failure
Authors: Anderson Cheryl , Deepak B.V. , Amoateng‐Adjepong Yaw , Zarich Stuart
Published: February 2007

Multidisciplinary disease management programs for congestive heart failure have been shown to substantially reduce read‐mission rates, resulting in a reduction of costs. These interventions, however, have typically included changes in medical management, making it difficult to quantitate the key elements of a successful program involving education, discharge planning, and transitional care in the outpatient setting. The investigators utilized an experienced cardiac nurse educator to coordinate a targeted inpatient congestive heart failure education program coupled with comprehensive discharge planning and immediate outpatient reinforcement through a coordinated nurse‐driven home health care program. The comprehensive intervention resulted in a marked reduction in 6‐month readmission rates, from 44.2% to 11.4% (p=0.01). The average total cost saving for each subject in the interventional group was $1541, based on the decreased utilization of both skilled nursing services and home health care during outpatient follow‐up. The costs to implement an inpatient education program were negligible, at $158 per subject. There was no difference in discharge medications or medical management protocols that would have influenced these results.
Monitoring Lung Resistivity Changes in Congestive Heart Failure Patients Using the Bioimpedance Technique
Authors: Zlochiver Sharon , Radai Michal M. , Barak‐Shinar Deganit , Ben‐Gal Tuvia , Yaari Vicky , Strasberg Boris , Abboud Shimon
Published: February 2007

The feasibility of a novel, dedicated system for monitoring lung resistivity in congestive heart failure patients, implementing a hybrid approach of the bioimpedance technique, was assessed in this preliminary study. Thirty‐three healthy volunteers and 34 congestive heart failure patients were measured with the PulmoTrace system (Cardiolnspect, Tel Aviv University, Tel Aviv, Israel) during tidal respiration, and the ability to monitor the respective lung resistivity values was assessed. Mean left and right lung resistivity values of 1205±163 and 1200±165 Ω·cm for the control group and 888±193 and 943±187 Ω·cm for the congestive heart failure group were found, indicating a significant (p<2·10−7) difference between the two groups. The results of long‐term monitoring of two patients during medical treatment are also shown. This hybrid approach system is believed to improve diagnostic capabilities and help physicians to better adjust medication dosage on a frequent basis.
Vascular Thrombosis During Support With Continuous Flow Ventricular Assist Devices: Correlation With Computerized Flow Simulations
Authors: Kar Biswajit , Delgado Reynolds M. , Radovancevic Branislav , Myers Timothy J. , Wadia Yasmin , Letsou George V. , Riaz Imran , Metcalfe Ralph , Gregoric Igor , Harting Matthew T.
Published: February 2007

Continuous flow pumps are increasingly used to treat severe heart failure. These pumps alter flow physiology by lowering pulsatility in the arterial circulation. In patients with peripheral stenosis, continuous flow pumps may lead to thrombosis of peripheral vessels, possibly predisposing to vascular thrombosis in areas of non‐flow‐limiting stenosis. The authors performed a computerized flow modeling simulation to analyze the effects of altered hemodynamics in a stenotic area. Drawing on previous clinical experience, we modeled a stenotic area in the common carotid artery. Computerized flow modeling revealed blood stagnation zones with low shear stress and velocity adjacent to the stenotic area during nonpulsatile flow. Such stagnation was not present during pulsatile flow. These results indicate a mechanism by which altered physiologic flow may accelerate occlusion of arterial conduits in patients with preexisting stenosis. This finding may be important for patients with continuous flow devices who have peripheral vascular disease; therefore, further study is warranted.
Are Myocardial Fibrosis and Diastolic Dysfunction Reversible in Hypertensive Heart Disease?
Authors: Weber Karl T.
Published: February 2007

Diastolic dysfunction is an important factor contributing to the appearance of symptomatic heart failure, particularly among elderly women with arterial hypertension. In hypertensive heart disease, the presence of cardiac fibrosis is an important determinant of abnormal myocardial stiffness that contributes to diastolic dysfunction. Recent studies indicate the feasibility of a pharmacology‐based regression of fibrosis and improvement in diastolic stiffness.
Standard Electrocardiographic and Signal‐Averaged Electrocardiographic Changes in Congestive Heart Failure
Authors: Madias John E.
Published: February 2007

A 54‐year‐old man with congestive heart failure and peripheral edema was monitored during treatment with serial electrocardiograms (ECGs) and two signal‐averaged ECGs. Weights and a host of ECG parameters were monitored. ECGs recorded in the 5 years before his index admission were also considered in the quantitative ECG analysis. Amelioration of his peripheral edema was associated with reduction of his weight and increase in the QRS and P‐wave amplitudes, and duration in QRS complexes and QT intervals in the ECGs, but unchanged signal‐averaged ECGs. This case report provides insight into the mechanism of the change in QRS duration in ECGs during changing edematous states resulting from clinical deterioration or improved compensation in patients with congestive heart failure.
Long‐Term Destination Therapy With the HeartMate XVE Left Ventricular Assist Device: Improved Outcomes Since the REMATCH Study
Authors: Long James W. , Kfoury Abdallah G. , Slaughter Mark S. , Silver Marc , Milano Carmelo , Rogers Joseph , Delgado Reynolds , Frazier O.H.
Published: February 2007

The Randomized Evaluation of Mechanical Assistance for the Treatment of Congestive Heart Failure (REMATCH) trial demonstrated increased 1‐ and 2‐year survival and improved quality of life for end‐stage heart failure patients implanted with the HeartMate VE Left Ventricular Assist Device (LVAD) (Thoratec Corporation, Pleasanton, CA) compared with optimal medical management. This is the first report of Destination Therapy (DT) experience since REMATCH and incorporates improvements with the HeartMate XVE LVAD and patient management. Forty‐two patients with end‐stage heart failure at higher volume institutions were supported with the LVAD over a duration of 26.7 patient years (mean 232 days). Compared with REMATCH, DT patients had a 40% lower rate of death (0.49 vs. 0.84 deaths per patient year). Kaplan‐Meier estimates of survival in the DT and REMATCH LVAD groups at 30 days were 90% and 81%, and at 1 year were 61% and 52%. The death rate due to sepsis was 8.3 times lower in DT patients (risk ratio, 0.12; 95% confidence interval, 0.02–0.90). DT patients were 2.1 times less likely to experience an adverse event (risk ratio, 0.47; 95% confidence interval, 0.35–0.63). These results demonstrate continued improvement with outcomes in long‐term DT with LVADs. Given that these DT patients were similar to those in the REMATCH trial, the improved outcomes likely reflect improvements in the HeartMate XVE LVAD and experience with patient management.
Current and Emerging Issues With B‐Type Natriuretic Peptide
Authors: Silver Marc A. , Rosendorff Clive , Berkowitz Robert , Peacock IV Franklin
Published: February 2007

A brief panel discussion was held on March 23, 2005, in New York City following a live symposium for primary care physicians discussing the roles of B‐type natriuretic peptide in a variety of cardiovascular diseases. The participants were Dr. Marc A. Silver, Advocate Christ Medical Center, Oak Lawn, IL; Dr. Clive Rosendorff, Mount Sinai School of Medicine, New York, NY and VA Medical Center, Bronx, NY; Dr. Robert Berkowitz, Hackensack University Medical Center, Hackensack, NJ; and Dr. W. Franklin Peacock IV, The Cleveland Clinic Department of Emergency Medicine, Cleveland, OH. Dr. Silver moderated the discussion. The panel gathered to review some of the questions that emerged from the symposium and the questions raised by the attendees. These are of interest and importance to all interested in heart failure and B‐type natriuretic peptide.
Continuous Heart Rate Variability From an Implanted Device: A Practical Guide for Clinical Use
Authors: Adamson Philip B.
Published: February 2007

Continuous measurement of spontaneous heart rate variability is now possible from permanently implanted devices and may contain information useful in the chronic management of patients with congestive heart failure. Since heart rate variability semi‐quantifies autonomic control of the heart, changes noted from continuous measurement provide insight into cardiac control system status, which may reflect clinical status of the patient. This review outlines clinical evidence supporting the use of heart rate variability derived from implanted electronic devices and suggests a practical application in an every day clinical setting for its use. Changes in continuously measured heart rate variability coupled with the absolute value of the standard deviation of the atrial‐to‐atrial activation period predict subsequent risk for decompensation and hospitalization. Prospective clinical trials will evaluate this approach and the use of such markers on health care utilization in populations of patients with long‐term chronic heart failure.
A US Food and Drug Administration Perspective on Cardiac Resynchronization and Ventricular Assist Device Trials
Authors: Faris Owen , Chen Eric , Berman Michael , Moynahan Megan , Zuckerman Bram
Published: February 2007

Cardiac resynchronization therapy and ventricular assist devices are two of the many US Food and Drug Administration‐regulated medical device technologies that are intended for patients with heart failure. Cardiac resynchronization therapy devices have been shown to significantly improve the quality and potentially the duration of life for patients with moderate‐to‐severe congestive heart failure and electrical dyssynchrony. Likewise, ventricular assist devices have benefited patients with end‐stage heart failure through both bridge‐to‐transplant and destination therapy. The pivotal trials that supported the first approvals for these devices, as well as subsequent trials, were shaped by unique technologic and patient‐related concerns. The US Food and Drug Administration has worked to understand these evolving concerns and the role each should play in the design of trials intended to demonstrate the safety and effectiveness of these critical devices.
A Rare Cause of Sudden Vision Loss in a Young Male: Papillary Fibroelastoma of the Aortic Valve
Authors: Ergun Kumral , Golbasi Zehra , Cagli Kerim , Altinsoy Ali , Mustafa Ulas Mahmut , Temucin Tulay , Arat Nurcan , Topaloglu Serkan , Deveci Bulent , Ertan Aylin
Published: February 2007

Cardiac papillary fibroelastoma (CPF) is a rare cardiac neoplasm predominantly affecting the cardiac valves. Although it is most commonly an incidental finding, it can result in life‐threatining complications, such as coronary and cerebral embolism, acute valvular dysfunction, and sudden death. In this report, we describe a case of a patient with aortic valve papillary fibroelastoma, which presented with sudden vision loss due to branch retinal artery occlusion. To the best of our knowledge, this is the third case of CPF‐related retinal artery embolism in English literature.
South Arabian antiquities in a private collection in Ar‐Riyad (Saudi Arabia)
Authors: ANTONINI S. , Mazzini G.
Published: February 2007

A Saudi Arabian private collection of South Arabian antiquities is presented here. The material includes an incense‐burner, two funerary stele, four funerary human faces and four inscriptions all probably from the Ma'rib area.
Long‐term effects of supportive therapy in periodontal patients treated with fibre retention osseous resective surgery. I: recurrence of pockets, bleeding on probing and tooth loss
Authors: Carnevale Gianfranco , Cairo Francesco , Tonetti Maurizio S.
Published: February 2007

Background: Periodontal surgery is indicated in the treatment of persistent pockets following cause‐related therapy. The aim of this study was to evaluate the long‐term effect of supportive therapy in periodontal patients treated with fibre retention osseous resective surgery.

Methods: Three‐hundred and four consecutive patients were identified and retrospectively examined while presenting for a supportive periodontal care (SPC) appointment (T2). All had received non‐surgical periodontal treatment and osseous resective surgery as needed, to obtain no sites with probing depth (PD) >3 mm before being enrolled in the SPC programme. The mean SPC duration for the patients was 7.8±3.2 years while the mean interval of SPC was 3.4±0.8 months.

Results: During SPC, a total of 67 teeth had been removed (0.9%). At T2, mean full‐mouth plaque scores (FMPS) was 13±11.3% and full‐mouth bleeding scores (FMBS) was 2±3%. In 98.5% of the sites, PD was minimal (3 mm). The majority of pockets at T2 showed PDs of 4–5 mm (83.4% of pockets). At the same time, the total number of pockets 6 mm was 68 and limited to 41 patients (13.8% of sample). Initial periodontal diagnosis of severe periodontitis, smoking habits, FMBS, number of teeth at completion of active periodontal therapy (T1), number of surgically treated teeth, number of teeth with furcation involvement and number of multi‐rooted teeth were associated with the number of pockets at T2. A total of 598 sites (2.1%) displayed bleeding on probing (BOP) at T2. The odds ratio of sites 4 mm or deeper to be BOP positive was 32.9 compared with sites of <3 mm depth. Gender, FMBS, FMPS, furcation involvements and overall number of pockets were associated with the number of bleeding pockets at T2.

Conclusion: Shallow PDs achieved by treatment of the persistent pockets by fibre retention osseous resective surgery can be maintained over time. These patients displayed minimal gingival inflammation and tooth loss during SPC.
Long‐term effects of supportive therapy in periodontal patients treated with fibre retention osseous resective surgery. II: tooth extractions during active and supportive therapy
Authors: Carnevale Gianfranco , Cairo Francesco , Tonetti Maurizio S.
Published: February 2007

Background: Long‐term tooth retention is the main objective of periodontal treatment. The aim of this retrospective study was to describe the prevalence and reasons of tooth extraction during active periodontal therapy (APT) and supportive periodontal care (SPC) in periodontal patients.

Material and Methods: Three hundred and four periodontal patients were examined. APT consisted of non‐surgical periodontal treatment and fibre retention osseous resective surgery, where needed, to obtain no sites with PD>3 mm. All patients participated in an SPC programme for 3–17 years (mean time 7.8 years).

Results: At the initial examination, 45% of the patients had moderate periodontitis and 41% severe periodontitis. During APT, 576 teeth were extracted (7.5%). The main reason for tooth extraction during APT was the presence of advanced periodontal lesions (44%). The number of tooth extractions was higher in cases with severe periodontitis. Extracted teeth showed a mean bone loss of 76% of the total root length. During SPT, a total of 67 teeth were removed (0.9%) in a subgroup of 50 patients. The clinical problems were primarily related to the incidence of root fracture (48%) and secondarily to the progression of periodontal disease (30%).

Conclusion: Prevalence of tooth extraction during APT is associated with the severity of periodontal disease. Tooth loss during supportive periodontal care may be negligible when a meticulous SPC programme is performed in patients where minimal probing depth is consequential to APT.
A randomized‐controlled trial of low‐dose doxycycline for periodontitis in smokers
Authors: Needleman Ian , Suvan Jean , Gilthorpe Mark S. , Tucker Richard , St George Geoff , Giannobile William , Tonetti Maurizio , Jarvis Martin
Published: February 2007

Background/Aim: Tobacco use reduces the effect of non‐surgical periodontal therapy. Host‐modulation with low‐dose doxycycline (LDD) might favour repair and promote an improved treatment response. The aim of this study was to investigate the effect of LDD in smokers on non‐surgical periodontal therapy.

Material and Methods: This was a parallel arm, randomized, identical placebo‐controlled trial with masking of examiner, care‐giver, participant and statistician and 6 months of follow‐up. Patients received non‐surgical therapy and 3 months of test or control drug. Statistical analysis used both conventional methods and multilevel modelling.

Results: Eighteen control and 16 test patients completed the study. The velocity of change was statistically greater for the test group for clinical attachment level −0.19 mm/month (95% CI=−0.34, 0.04; p=0.012) and probing depth 0.30 mm/month (95% CI=−0.42, −0.17; p<0.001). However, no differences were observed for absolute change in clinical or biochemical markers at 6 months.

Conclusions: This study does not provide evidence of a benefit of using LDD as an adjunct to non‐surgical periodontal therapy in smokers.
Melatonin and type 2 diabetes – a possible link?*
Authors: Peschke Elmar , Stumpf Ina , Bazwinsky Ivonne , Litvak Liudmila , Dralle Henning , Mühlbauer Eckhard
Published: February 2007

Abstract:  The aim of the present study was to determine the existence of melatonin membrane receptors and to examine the mRNA expression of nuclear orphan receptors in human pancreatic tissue, in an effort to explain differences between type 2 diabetic and metabolically healthy patients. Molecular and immunocytochemical investigations established the presence of the melatonin membrane receptors MT1 and MT2 in human pancreatic tissue and, notably, also in the islets of Langerhans. Results of a calculation model to determine mRNA expression ratios, as well as subjective analysis of immunoreactions, showed elevated MT1 receptor expression in comparison with MT2 expression. mRNA transcript levels of melatonin receptors appeared to be significantly higher in type 2 diabetic patients than in a control group. An upregulation of receptor expression in type 2 diabetic patients was also observed in immunocytochemical investigations. In addition, transcripts of the nuclear orphan receptors RORα, RZRβ, RORγ and RevErbα were detected in human pancreatic tissue and islets. In correlation with membrane melatonin receptors, data indicate increased mRNA expression levels of RORα, RZRβ, and RORγ in type 2 diabetic patients. Thus, our data demonstrate the existence of the melatonin membrane receptors MT1 and MT2 as well as mRNA expression of nuclear orphan receptors in human pancreatic tissue, with upregulated expression levels in type 2 diabetic patients.
DYNAMIC HELICAL COMPUTED TOMOGRAPHY OF THE PITUITARY GLAND IN HEALTHY DOGS
Authors: Van Der VLUGT‐MEIJER ROSELINDA H. , MEIJ BJÖRN P. , VOORHOUT GEORGE
Published: February 2007

Dynamic helical computed tomography (CT) of the pituitary gland can be used to image the three‐dimensional shape and dimensions of abnormalities within the pituitary gland. The aim of this study was to develop a protocol for dynamic helical CT of the pituitary gland in healthy dogs as a future reference study for patients with pituitary disease. Dynamic helical series of nine scans of the pituitary gland during and following contrast medium injection were performed in six healthy dogs using the following protocols: a series with 1 mm collimation and a table feed per X‐ray tube rotation of 2 mm (pitch of 2) in six dogs, a series with 2 mm collimation and pitch of 2 in three dogs, and a series with 1 mm collimation and pitch of 1 in three other dogs. Multiplanar reconstructions of the images were made using a reconstruction index of 0.5. Images of all series were assessed visually for enhancement of the arteries, the neurohypophysis, and the adenohypophysis. The enhancement pattern of the neurohypophysis was distinguished adequately from that of the adenohypophysis in five dogs that were scanned with 1 mm collimation and pitch of 2, but the difference was less discernable when the other protocols were used. The carotid artery, its trifurcation, and the arterial cerebral circle were best visualized in dorsal reconstructions. Dynamic helical CT of the pituitary gland in healthy dogs can be performed with 1 mm collimation and pitch of 2, and a scan length that includes the entire pituitary region. Using this protocol, with the specific scanner used, the neurohypophysis, the adenohypophysis, and the surrounding vascular structures are adequately visualized.