bluuebunny/crossref_metadata_2025 huggingface dataset:
Combination of B‐Type Natriuretic Peptide Levels and Non‐Invasive Hemodynamic Parameters in Diagnosing Congestive Heart Failure in the Emergency Department
Authors: Barcarse Erin , Kazanegra Radmila , Chen Amy , Chiu Albert , Clopton Paul , Maisel Alan
Published: February 2007

This study aimed to assess whether the combination of a B‐type natriuretic peptide (BNP) level with various noninvasive hemodynamic parameters can help physicians more quickly and accurately diagnose congestive heart failure and determine the type of left ventricular dysfunction present in patients presenting to the emergency department with dyspnea. Subjects were 98 men (aged 64.57±1.23 years) that presented to the VA San Diego Healthcare System. Hemodynamic parameters were measured using impedance cardiography, and BNP levels were quantified using a rapid immunoassay. All patients with a BNP <100 pg/mL (n=37) had no evidence of congestive heart failure 97% of the time. In those with a BNP >100 pg/mL (601 ±55 pg/mL; n=61), a cardiac index of 2.6 L/min/m2 is 65% sensitive and 88% specific in determining systolic dysfunction. In patients with a BNP >100 pg/mL, a multivariate model consisting of noninvasive hemodynamic measurements was able to predict cardiac deaths, readmissions, and emergency department visits within 90 days with 83% accuracy. The authors conclude that, in patients presenting to an emergency department with dyspnea, the addition of impedance cardiography measurements to BNP level measurements will more effectively diagnose congestive heart failure and determine both the type of heart dysfunction and the severity of illness.
B‐Type Natriuretic Peptide: The Level and the Drug—Partners in the Diagnosis and Management of Congestive Heart Failure
Authors: Bhalla Vikas , Willis Scott , Maisel Alan S.
Published: February 2007

Over the past 100 years, cardiovascular disease has become a leading cause of morbidity and mortality worldwide. A tremendous increase in incidence and prevalence of heart failure has been observed in the United States. The cost of managing heart failure itself is $56 billion a year, 70% of which is due to hospitalization. Although we have made tremendous advances in our understanding of the pathophysiology and treatment of congestive heart failure, the diagnosis of the disease still remains difficult. Unfortunately, the signs and symptoms of congestive heart failure are nonspecific. The recognition of the role of B‐type natriuretic peptide as an objective marker for the diagnosis, severity, and prognosis of acute coronary syndromes and congestive heart failure was truly a breakthrough for clinicians and patients faced with cardiovascular disease. Also, the high levels of endogenous B‐type natriuretic peptide may be released as a“distress hormone” that is, these levels are no longer effective in maintaining the balance of vasoconstriction and vasodilation. Hence it makes intuitive and practical sense that giving back B‐type natriuretic peptide in the form of exogenous nesiritide might restore neurohormonal homeostasis. Therefore, lately there has been a lot of interest shown in the use of recombinant B‐type natriuretic peptide as a drug. This article reviews the literature concerning the use of these peptides in a variety of clinical scenarios and the use of recombinant B‐type natriuretic peptide in decompensated heart failure.
Effect of Bisoprolol on Right Ventricular Function and Brain Natriuretic Peptide in Patients With Heart Failure
Authors: Beck‐da‐Silva Luís , De Bold Adolfo , Davies Ross A. , Chow Benjamin J.W. , Ruddy Terrence D. , Fraser Margaret , Struthers Christine , Haddad Haissam
Published: February 2007

Beta‐blocker use improves left ventricular ejection fraction (LVEF) in patients with heart failure. A similar effect of β blockers on right ventricular function has been proposed, although the effect of bisoprolol, a highly selective β‐1 blocker, on right ventricular function has not been assessed. This study investigated the short‐term effect of bisoprolol on right ventricular function in chronic heart failure patients. A cohort of 30 heart failure patients who were not taking β blockers at baseline was studied prospectively. Right ventricular ejection fraction (RVEF) and LVEF were measured at both baseline and 4 months by radionuclide angiography. Bisoprolol was up‐titrated during four monthly visits by a preestablished protocol to a target dose of 10 mg/d. The dose of vasodilators was not changed. Quality of life and brain natriuretic peptide level were assessed. Mean age was 62.7±14.3 years. Baseline RVEF was 30.7%±6.3% and baseline LVEF was 21.7%±9.4%. Mean bisoprolol dose reached was 5.3±3.9 mg daily. At 4 months, RVEF significantly increased by 7.1 % (95% confidence interval, 3.9–10.2; p=0.0001) and LVEF also increased significantly by 7.9% (95% confidence interval, 4.0%–11.9%p=0.0003). Quality‐of‐life score improved from 42.8 to 30.8 (p=0.047). No correlation was found between brain natriuretic peptide levels and RVEF. Bisoprolol treatment for 4 months resulted in a significant improvement of RVEF, which paralleled the improvement of LVEF.
Persistent Orthopnea and the Prognosis of Patients in the Heart Failure Clinic
Authors: Da Silva Luís Beck , Mielniczuk Lisa , Laberge Marc , Anselm Anjali , Fraser Margaret , Williams Kathryn , Haddad Haissam
Published: February 2007

Heart failure (HF) is a public health problem with ever‐growing costs. Signs such as jugular venous pressure and third heart sound have been associated with disease prognosis. Symptoms of heart failure are frequently subjective, and their real value is often overlooked. The authors aimed to assess the relationship between orthopnea and left ventricular ejection fraction (LVEF) and hospitalization rate in patients referred to the HF clinic. One hundred fifty‐three new consecutive patients referred to the HF clinic from September 2001 to July 2002 were reviewed. Information about orthopnea was available at baseline and at a 6‐month to 1‐year follow‐up. One hundred thirty‐one patients had a baseline multigated radionuclide ventriculogram scan, and 68 patients had a follow‐up multigated radionuclide ventriculogram scan available. The patients were divided into groups by presence of orthopnea and compared with respect to LVEF and hospitalization rate. Patients with or without orthopnea had similar LVEFs at baseline (32%±17% vs. 33%±15%, respectively; p=NS). However, patients who were orthopnea‐free at the follow‐up visit had a significant LVEF improvement whereas patients with ongoing orthopnea at follow‐up had no LVEF improvement (11%±13% vs. −1%±6%; p<0.001). Patients who presented with persistent orthopnea had a significantly higher rate of hospitalization (64% vs. 15.3%; p=0.0001). Persistent orthopnea in HF patients is associated with a significantly higher rate of hospitalization and with worsening or no improvement in LVEF. Patients with persistent orthopnea may require a more aggressive approach to improve their outcome. This result may help centers with limited access to LVEF measurements to better stratify HF patients' risk.
Potential of the Right Ventricular Endomyocardial Biopsy to Diagnose and Assist in the Management of Congestive Heart Failure: Insights From Recent Clinical Trials
Authors: Wu Lambert A. , Cooper Leslie T.
Published: February 2007

In the United States congestive heart failure is most commonly due to ischemic cardiomyopathy, but nonischemic causes of cardiomyopathy can also result in congestive heart failure. Indeed, nonischemic dilated cardiomyopathy affects approximately 100,000 persons in the United States and is responsible for 45% of heart transplants. Although these patients undergo thorough cardiovascular evaluation, a specific cause is usually not found. Endomyocardial biopsy may yield diagnostic and prognostic information in this setting, and there has been a renewed interest in the use of endomyocardial biopsy in the evaluation of specific subsets of patients with congestive heart failure to identify potentially treatable myocarditides. However, the role of endomyocardial biopsy in the evaluation of patients with nonischemic cardiomyopathy is ill defined. In this review, the authors discuss the latest data on the risks and the utility of endomyocardial biopsy in the management of heart failure in the setting of dilated cardiomyopathy and specific myocarditides. Gaps in present knowledge and the obstacles to research in this area are identified.
Mechanical Bridging to Improvement in Severe Acute ‘Nonischemic, Nonmyocarditis’ Heart Failure
Authors: Frazier O.H. , Reynolds Delgado M. , Scroggins Nanci , Odegaard Peggy , Kar Biswajit , Radovancevic Branislav , Broom Cindy
Published: February 2007

Improved myocardial function has been observed in patients with acute myocarditis who have had short‐term support with a ventricular assist system. Additionally, a limited number of patients with nonischemic cardiomyopathy have undergone successful device explantation after their myocardial function improved during ventricular assist system support. The authors present their experience with four patients who had acute, severe heart failure without coronary artery disease or biopsy‐proven myocarditis. After receiving prolonged ventricular assist system support, all four patients had significantly improved left ventricular function, returning to New York Heart Association functional class I without inotropic therapy. In each case, dobutamine stress echocardiography and invasive hemodynamic tests were performed to confirm improvement of cardiac function before device explantation was undertaken. In all four cases, device explantation was followed by early successful maintenance of left ventricular function. These cases reveal a unique clinical syndrome that may be successfully treated with early institution of ventricular assist system support followed by explantation after myocardial recovery.
Medical Management of Porto‐Pulmonary Hypertension and Right Heart Failure Prior to Living‐Related Liver Transplantation
Authors: Sulica Roxana , Emre Sukru , Poon Michael
Published: February 2007

Porto‐pulmonary hypertension and right heart failure are relatively prevalent complications of end‐stage liver disease and may increase mortality of patients undergoing cadaveric orthotopic liver transplantation. Even with extensive pre‐transplant evaluation, these complications are frequently diagnosed unexpectedly in the operating room and transplant procedure may need to be aborted due to high perioperative mortality from both right and left ventricular failure. Living‐related liver transplantation is a new surgical alternative to cadaveric liver transplantation, but presence of porto‐pulmonary hypertension increases its postoperative mortality as well. Due to inherent elective nature, however, living‐related liver transplantation may allow for preoperative hemodynamic optimization and treatment of right ventricular failure. To the authors' knowledge, this is the first reported case of an adult patient with porto‐pulmonary hypertension who underwent successful living‐related liver transplantation. Favorable transplantation outcome was obtained in this case through good hemodynamic control with long‐term IV epoprostenol therapy, preoperative right heart calcification, and perioperative administration of pulmonary vasodilators and inotropic agents.
Comparison of Impedance Cardiography to Direct Fick and Thermodilution Cardiac Output Determination in Pulmonary Arterial Hypertension
Authors: Yung Gordon L. , Fedullo Peter F. , Kinninger Katie , Johnson Wayne , Channick Richard N.
Published: February 2007

Cardiac output (CO) is an important diagnostic and prognostic tool for patients with ventricular dysfunction. Pulmonary hypertension patients undergo invasive right heart catheterization to determine pulmonary vascular and cardiac hemodynamics. Thermodilution (TD) and direct Fick method are the most common methods of CO determination but are costly and may be associated with complications. The latest generation of impedance cardiography (ICG) provides noninvasive estimation of CO and is now validated. The purpose of this study was to compare ICG measurement of CO to TD and direct Fick in pulmonary hypertension patients. Thirty‐nine enrolled patients were analyzed: 44% were male and average age was 50.8±17.4 years. Results for bias and precision of cardiac index were as follows: ICG vs. Fick (−0.13 L/min/m2 and 0.46 L/min/m2), TD vs. Fick (0.10 L/min/m2 and 0.41 L/min/m2), ICG vs. TD (respectively, with a 95% level of agreement between −0.72 and 0.92 L/min/m2; CO correlation of ICG vs. Fick, TD vs. Fick, and ICG vs. TD was 0.84, 0.89, and 0.80, respectively). ICG provides an accurate, useful, and cost‐effective method for determining CO in pulmonary hypertension patients, and is a potential tool for following responses to therapeutic interventions.
Comparison of Changes in Ejection Fraction to Changes in Impedance Cardiography Cardiac Index and Systolic Time Ratio
Authors: Parrott Charles W. , Burnham Kenneth M. , Quale Cheryl , Lewis Deborah L.
Published: February 2007

Ejection fraction (EF) is the most common measure of left ventricular function in patients with heart failure. However, serial measurements of EF are costly and not practical for guiding frequent management decisions. Impedance cardiography (ICG) provides noninvasive hemodynamic measures with proven validity. The purpose of this study was to assess how changes in ICG parameters compared with changes in EF in heart failure subjects enrolled in a comprehensive outpatient management program. Retrospective chart review identified 13 subjects with two sets of paired echocardiography and ICG measurements (before and after treatment in an outpatient heart failure clinic setting). Mean age was 69±11 years, etiology was 54% ischemic heart disease, and mean New York Heart Association class was 2.5±0.5. The mean time between pre‐ and posttreatment EF measurements was 198±161 days. Changes in cardiac index and systolic time ratio by ICG were compared with changes in EF by echocardiography. From entry to final measurement, mean EF improved 9%±13%. Seven (54%) subjects had >5% improvement in EF, three (23%) had >5% decrease, and three had <5% change. Changes in ICG cardiac index and systolic time ratio were highly correlated with changes in EF (0.85, −0.73). ICG may be a practical, reliable, and cost‐effective method of monitoring left ventricular function and guiding management decisions.
Association of Impedance Cardiography Parameters With Changes in Functional and Quality‐of‐Life Measures in Patients With Chronic Heart Failure
Authors: Vijayaraghavan Kris , Crum Sue , Cherukuri Sangita , Barnett‐Avery Leslie
Published: February 2007

Assessment and prognosis of chronic heart failure is often difficult due to a lack of objective and easily obtainable parameters that accurately reflect disease status. This study was conducted to determine whether impedance cardiography (ICG) parameters were associated with changes in functional and quality‐of‐life measures in chronic heart failure patients. Retrospective chart review identified 64 patients (73% male, aged 73±13 years) with paired ICG measurements followed for 180±113 days. Outcome measures were changes in New York Heart Association class, 6‐minute walk distance, patient visual analog scale score, and Minnesota Living with Heart Failure Questionnaire score. Measures of ICG, heart rate and blood pressure, left ventricular ejection fraction, and B‐type natriuretic peptide levels were assessed for their association with outcome measures. From baseline to final evaluation, there were significant changes (p<0.05) in New York Heart Association class (from 3.2±0.5 to 3.0±0.6), 6‐minute walk distance (from 668±380 m to 874±390 m), patient visual analog scale score (from 49±10 to 64±20), Minnesota Living with Heart Failure Questionnaire score (from 54±22 to 39±22), and ICG parameters of stroke index (from 38±9 to 41±8), left ventricular ejection time (from 273±42 to 291±33), and systolic time ratio (from 0.56±0.2 to 0.52±0.2). Changes in multivariate ICG parameters were significantly correlated to changes in New York Heart Association class (R, 0.80), 6‐minute walk distance (R, 0.94), patient visual analog scale score (R, 0.69), and Minnesota Living with Heart Failure Questionnaire score (R, 0.67). ICG provides objective data that reflects changes in chronic heart failure disease status and treatment effectiveness.
Utility of Impedance Cardiography to Determine Cardiac vs. Noncardiac Cause of Dyspnea in the Emergency Department
Authors: Springfield Charles L. , Sebat Frank , Johnson David , Lengle Steven , Sebat Christian
Published: February 2007

Determining the correct diagnosis of patients with dyspnea can be challenging. Early and accurate determination of the cause of dyspnea is vital in instituting timely and appropriate interventions. Hemodynamic parameters may aid in the evaluation of dyspnea, but are difficult to assess by physical exam. Impedance cardiography (ICG) is a newly validated method of determining hemodynamic parameters noninvasively. The purpose of this study was to determine the accuracy in differentiating cardiac from noncardiac causes of dyspnea utilizing ICG‐derived hemodynamic parameters compared with that of emergency department (ED) physicians after initial history, physical, and laboratory tests. The final diagnosis, which was made retrospectively after review of the patient's hospital record by a senior ED physician blinded to the ICG data, was compared with the treating ED physician's and the ICG diagnoses. Thirty‐eight patients who presented with dyspnea to a community ED were included in the study. There were significant differences in values of cardiac index by ICG (2.2 vs. 3.1; p<0.0001), systolic time ratio (0.52 vs. 0.37; p<0.01) and velocity index (32.9 vs. 42.7; p<0.01) between the cardiac and noncardiac groups, respectively. ICG measurements demonstrated greater sensitivity (92 vs. 83%), specificity (88 vs. 77%), and positive and negative predictive values (79 vs. 63% and 96 vs. 91%, respectively) compared with the ED physician in distinguishing cardiac from noncardiac cause of dyspnea. ICG can aid ED physicians in making more rapid and accurate determinations of cardiac vs. noncardiac cause of dyspnea.
Evaluation of Impedance Cardiography as an Alternative to Pulmonary Artery Catheterization in Critically Ill Patients
Authors: Silver Marc A. , Cianci Pamela , Brennan Sharon , Longeran‐Thomas Helen , Ahmad Faheem
Published: February 2007

Invasive pulmonary artery catheterization has historically been the method of choice for the evaluation of hemodynamic status. Impedance cardiography (ICG) is an accurate, noninvasive technique to obtain hemodynamic status information without the risk and cost associated with invasive methods. The purpose of this prospective, observational study was to determine whether the availability of ICG could decrease the need for placement of a pulmonary artery catheter in critically ill patients in coronary care units. After the need for hemodynamic data was determined, ICG parameters were provided to the attending physician who then decided whether pulmonary artery catheter insertion was still necessary. Of 107 subjects enrolled in the study, 14 (13% 95% confidence interval, 7.3%–21.0%) were judged by the treating physicians to have indications for hemodynamic monitoring. In these subjects, the provision of ICG data allowed the physician to avoid placement of a pulmonary artery catheter in 10/14 patients (71% 95% confidence interval, 41.9%–91.6%). When ICG was utilized, clinicians reported that the information was helpful in 10/10 patients (100% 95% confidence interval, 74.1%–100.0%) and improved outcome in 6/10 patients (60% 95% confidence interval, 26.2%–87.8%). ICG can replace the pulmonary artery catheter in coronary care unit patients, and clinicians utilizing ICG believe it aids medical decision making and improves patient outcomes.
Jarvik 2000 FlowMaker Axial‐Flow Left Ventricular Assist Device Support for Management of Refractory Ventricular Arrhythmias
Authors: Wadia Yasmin , Delgado Reynolds M. , Odegaard Peggy , Frazier O.H.
Published: February 2007

Chronic congestive heart failure is not uncommonly associated with ventricular arrhythmias. In a small percentage of these cases, the arrhythmias may become refractory to medical therapy and exacerbate the patient's underlying heart failure. The authors report such a case, in which ventricular failure necessitated insertion of a Jarvik 2000 FlowMaker left ventricular assist device (Jarvik Heart Inc., New York, NY). In addition to normalizing the cardiac output, this axial‐flow device controlled the previously unremitting ventricular arrhythmia.
Surgical Ventricular Restoration: Technique and Outcomes
Authors: Conte John V.
Published: February 2007

Surgical ventricular restoration is a surgical procedure developed in an attempt to reverse the negative remodeling that occurs following myocardial infarction. The goal of the procedure is to: 1) reduce the size and restore the normal elliptical shape of the heart; 2) perform a complete myocardial revascularization; and 3) repair any mitral insufficiency. This article will review the surgical procedure and describe outcomes achieved with surgical ventricular restoration.
Measuring the Dyspnea of Decompensated Heart Failure With a Visual Analog Scale: How Much Improvement Is Meaningful?
Authors: Ander Douglas S. , Aisiku Imoigele P. , Ratcliff Jonathan J. , Todd Knox H. , Gotsch Karen
Published: February 2007

Patients presenting to the emergency department with heart failure are evaluated based on the subjective sensation of dyspnea. In this study, the authors sought to determine the change in dyspnea, measured by a visual analog scale (VAS), which is associated with a meaningful change in the patient's perception and the effect of dyspnea severity on the VAS. In this prospective, observational study the authors defined a meaningful change in VAS dyspnea as the difference between VAS scores when patients reported “a little less difficulty breathing” or “a little more difficulty breathing.” Seventy‐four patients were evaluated, and the mean for a meaningful change in VAS was 21.1 mm (95% confidence interval, 12.3–29.9 mm). Patients that recorded higher index VAS scores had a significantly greater change in VAS. VAS scores and the changes with treatment provide the treating physician with another means to assess the effects of their interventions.
Case Report. Use of Noninvasive Hemodynamics to Aid Decision Making in the Initiation and Titration of Neurohormonal Agents
Authors: Summers Richard L. , Parrott Charles W. , Quale Cheryl , Lewis Deborah L.
Published: February 2007

Angiotensin‐converting enzyme inhibitors, β adrenergic blockers, and nesiritide are pharmacologic agents for heart failure with both short‐ and long‐term neurohormonal and hemodynamic effects. Angiotensin‐converting enzyme inhibitors and β adrenergic blockers reduce morbidity and mortality in chronic heart failure. Higher doses may result in better outcomes than lower doses, but concern about hemodynamic tolerance is a major barrier to the initiation and up‐titration of these agents. Nesiritide is a newer neurohormonal agent with proven efficacy and safety for use in decompensated heart failure, but appropriate patient selection has been challenging for clinicians. Like vasodilators, nesiritide may be underutilized in heart failure treatment. Impedance cardiography is a newer, noninvasive monitoring technology that can accurately measure hemodynamic parameters. Impedance cardiography is being used with increasing frequency by clinicians to guide therapy in patients with heart failure and has been proposed in heart failure treatment algorithms. Three case reports are presented to illustrate how hemodynamic data using impedance cardiography can be utilized in the initiation and titration of neurohormonal agents.
Prevalence of Sleep Disordered Breathing in a Heart Failure Program
Authors: Trupp Robin J. , Hardesty Peggy , Osborne Julia , Selby Shelly , Lamba Sumant , Ali Vaqar , Jansen Donald E. , Kunik Cherie L. , Abraham William T.
Published: February 2007

Recent data show that a high percentage of patients with systolic left ventricular dysfunction have sleep‐disordered breathing (SDB), contributing to the incidence of morbidity and mortality in heart failure. This study examines the prevalence of sleep disorders in stable heart failure patients regardless of ejection fraction. On three consecutive days in a heart failure clinic, all patients were asked to participate in a screening for SDB. This screening involved the placement of an outpatient device (ClearPath, Nexan, Inc., Alpharetta, GA), which collects thoracic impedance, oxyhemoglobin saturation, and 2‐lead electrocardiogram data. Sixteen patients (42%) had moderate or severe SDB, and 22 patients (55%) had mild or no significant SDB. Fourteen of the 16 patients with moderate or severe SDB subsequently received treatment by confirming SDB and the continuous positive airway pressure in a sleep lab. Forty‐two percent of patients with stable heart failure presenting to a heart failure clinic screened positive for SDB, despite receiving optimal standard of care.
Pharmacogenetics in Heart Failure: Genomic Markers of Endothelial and Neurohumoral Function
Authors: McNamara Dennis M.
Published: February 2007

There is a high potential for pharmacogenetic interaction in the management of many diseases including heart failure. Although genetic tailoring of therapy is not yet a common medical practice, it is foreseeable that some forms of genetic targeting will become standard care by the end of the current decade. This review will summary how genetic variation in two genes involved in both endothelial function and heart failure pathogenesis, angiotensin‐converting enzyme and endothelial nitric oxide synthase, influence both heart failure outcomes and the effects of standard therapies
Endothelial Dysfunction and Nitric Oxide Enhancing Therapy: A New Approach to the Treatment of Heart Failure
Authors: Taylor Anne L.
Published: February 2007

Despite ethnic differences in heart failure prevalence, risk profiles, and outcomes, no clinical trials have been designed to prospectively examine the mechanisms responsible for these differences. The African‐American Heart Failure Trial is the first prospective trial designed to test a novel therapy that enhances endothelial function and nitric oxide bioavailability in African‐American patients with advanced heart failure.
Usefulness of B‐Type Natriuretic Peptide as a Predictor of Treatment Outcome in Pulmonary Arterial Hypertension
Authors: Park Myung H. , Scott Robert L. , Uber Patricia A. , Ventura Hector O. , Mehra Mandeep R.
Published: February 2007

We examined the utility of early modulation B‐type natriuretic peptide (BNP) levels in 20 pulmonary arterial hypertension patients as a marker of response to epoprostenol therapy. The baseline BNP level was 828±217 pg/mL. A total of 19 hospitalizations and one death occurred in nine patients during 11.0±1.8 months. At baseline, a trend toward higher BNP level was observed among the event‐free (Group A) as compared with clinical event patients (Group B) (1090±372 vs. 510±235 pg/mL, respectively; p=0.08). After 3 months on epoprostenol, a significant reduction among Group A occurred while Group B demonstrated an increase (288±92 vs. 610±121 pg/mL, p=0.04). A comparison of percent reduction in BNP level demonstrated a −70±7% change among Group A and an 11±19% increase in Group B (p=0.005). A decrease in BNP level of ≥50% during the first 3 months on epoprostenol was strongly predictive of event‐free survival (p=0.003). This investigation establishes the utility of BNP for predicting response to epoprostenol therapy in pulmonary arterial hypertension.
Decompensated Heart Failure: Is There a Role for the Outpatient Use of Nesiritide?
Authors: Yancy Clyde W. , Burnett John C. , Fonarow Gregg C. , Silver Marc A.
Published: February 2007

Heart failure (HF) management has seen enormous advances in the past two decades, including publication of HF management guidelines targeted at further reduction of morbidity and mortality. Nonetheless, the morbidity of HF has steadily increased and now represents one of the largest health care expenditures in this country. Because hospitalization for HF is most likely for patients with more advanced HF, they share a disproportionate burden of the hospitalization costs and will require treatment regimens beyond the current guidelines, if this burden is to be alleviated. In June 2004, a group of investigators who helped establish the natriuretic peptide treatment paradigm, met to discuss the potential role of nesiritide as an outpatient treatment option for patients with symptomatic HF who were at high risk for repeated admissions, a syndrome now described as “chronic decompensated HF.” This report presents their considerations on the contribution of natriuretic peptide physiology to the amelioration of progressive left ventricular dysfunction, the therapeutic use of B‐type natriuretic peptide, and its potential application to the outpatient management of acute and chronic decompensated HF. The use of outpatient IV nesiritide was considered a promising treatment option for symptomatic chronic decompensated HF patients that merits further investigation. Such an approach, once validated, should be integrated into an evidence‐based HF disease management program.
Stem Cell Therapy for the Heart
Authors: Wold Loren E. , Dai Wangde , Sesti Casilde , Hale Sharon L. , Dow Joan S. , Martin Bradley J. , Kloner Robert A.
Published: February 2007

Cellular cardiomyoplasty is an expanding field of research that involves numerous types of immature cells administered via several modes of delivery. The purpose of this review is to investigate the benefits of different types of cells used in stem cell research as well as the most efficient mode of delivery. The authors also present data showing that stem cells isolated from bone marrow are present at both 2 weeks and 3 months after engraftment in a myocardial infarction. These cells express muscle markers at both time points, which suggests that they have begun to differentiate into cardiomyocytes. Several questions must be answered, however, before stem cells can be used routinely in the clinic. Once these questions have been addressed, the use of stem cells in clinical practice can be realized.
A Comparison of Nesiritide vs. Epoprostenol in a Patient With Precapillary Pulmonary Hypertension Due to Scleroderma Complicated by Postcapillary Pulmonary Hypertension
Authors: Zakir Ramzan M. , Berkowitz Robert L. , Saric Muhamed , Ashtyani Hormoz
Published: February 2007

To the best of our knowledge, acute decompensated left‐sided heart failure with preserved left ventricular ejection fraction in a patient with scleroderma has not been previously reported. We describe a patient with severe pulmonary hypertension due to limited scleroderma in whom nesiritide led to marked reductions in pulmonary arterial and capillary wedge pressure as well as resolution of symptoms and pulmonary edema. Subsequent epoprostenol use was associated with an increase in pulmonary capillary wedge pressure and a recurrence of pulmonary edema. Thus, nesiritide may be the preferred agent in scleroderma patients with severe pulmonary hypertension and preserved left ventricular systolic function since epoprostenol may lead to adverse hemodynamic effects.
Implantable Pacing Devices and Sleep Apnea: Implications for Diagnosis and Therapy
Authors: Shalaby Alaa A.
Published: February 2007

Sleep apnea has been increasingly recognized for its prevalence and its impact on cardiovascular health. The disorder has considerable impact on cardiovascular disease states, particularly congestive heart failure. Implantable cardiac pacing devices may have a role in both the diagnosis and therapy of sleep apnea, which may be of particular importance given the seemingly wide coprevalence of cardiac disorders and sleep apnea.
Cost‐Effective Strategies to Screen for Left Ventricular Systolic Dysfunction in the Community—A Concept
Authors: Senior Roxy , Galasko Gavin
Published: February 2007

Early detection of heart failure caused by left ventricular systolic dysfunction (LVSD) is important, since early treatment has been shown to retard the progression of heart failure. While traditional echocardiography remains the standard for the detection of LVSD, electrocardiography and serum brain natriuretic peptide have also been shown to predict LVSD. Recently, hand‐held echocardiography systems have been shown to have high predictive accuracy for assessment of LVSD. With the availability of the above bedside and relatively less‐costly techniques, compared with traditional echocardiography, the major question now is what is the most cost‐effective strategy for screening subjects for LVSD. To date, no studies have systematically addressed this issue, but preliminary data are becoming available. This review article discusses the pros and cons of various investigative strategies and likely cost‐effectiveness of each strategy to screen for LVSD.
Mesenchymal Stem Cells: Future Source for Reparative Medicine
Authors: Bhatia Rinky , Hare Joshua M.
Published: February 2007

Current treatments for ischemic cardiomyopathy are aimed toward minimizing the deleterious consequences of damaged myocardium. The possibility of treating heart failure by generating new myocardium and vascular structures has provided major impetus for recent stem cell research. Mesenchymal stem cells (MSCs), also referred to as marrow stromal cells, differentiate into a wide variety of lineages, including myocardial smooth muscle and possibly endothelial cells. The multilineage potential of MSCs, their ability to elude detection by the host's immune system, and their relative ease of expansion in culture make MSCs a very promising source of stem cells for transplantation. This paper reviews animal and human trials studying the role of MSCs in cardiomyogenesis and vasculogenesis in postinfarct myocardium, factors that stimulate MSC differentiation, routes of MSC delivery, and methods of detecting MSC engraftment.
The Relationship of Quality of Life, Depression, and Caregiver Burden in Outpatients With Congestive Heart Failure
Authors: Hooley Peter J.D. , Butler Gordon , Howlett Jonathan G.
Published: February 2007

Primary caregivers of patients with congestive heart failure withstand enormous burden, often sacrificing their own quality of life. The relationship between caregiver burden and depression and patient quality of life and depression in this setting is unknown. Fifty outpatients were prospectively administered the Minnesota Living with Heart Failure Questionnaire and Beck Depression Inventory II (BDI‐II). Caregivers were administered the Zarit Caregiver Burden Interview and BDI‐II. The mean quality of life score was 35, and 26% had a BDI‐II score >10. The mean Zarit Caregiver Burden Interview score was 16. Minnesota Living with Heart Failure Questionnaire, BDI‐II, and Zarit Caregiver Burden Interview scores were all associated with lower ejection fraction, need for hospitalization, increased number of medications, and comorbidities. Patient Minnesota Living with Heart Failure Questionnaire score correlated with patient BDI‐II, caregiver BDI‐II, and Zarit Caregiver Burden Interview scores. Caregiver burden score correlated with both caregiver BDI‐II and patient BDI‐II. Death or hospitalization at 6 months was associated with caregiver burden and depressive symptoms and with patient quality of life and depressive symptoms. Caregivers of patients with congestive heart failure experience high caregiver burden and prevalence of depressive symptoms, which are related to the patient disease burden.
Mineralocorticoid Receptor Is Overexpressed in Cardiomyocytes of Patients With Congestive Heart Failure
Authors: Yoshida Masahiro , Ma Jun , Tomita Tsutomu , Morikawa Norihiro , Tanaka Nobuyoshi , Masamura Katsuhiko , Kawai Yasuyuki , Miyamori Isamu
Published: February 2007

Mineralocorticoid receptors (MRs) have been identified in the human cardiovascular tissues. We determined MR expression in the failing heart to clarify the mechanism of action of aldosterone antagonist in the treatment of congestive heart failure. MR protein and MR mRNA content were detected by immunohistochemical staining and in situ hybridization in the cardiac tissues. Immunohistochemical staining of the receptor, as well as in situ hybridization of MR mRNA, was dense in cardiomyocytes of the failing left ventricle as compared with the controls. The staining ratio of the cytoplasm to the interstitium showed that MRs were located mainly in the cytoplasm. The cytoplasm to the interstitium in the failing left ventricle was 1.53±0.13, which was significantly higher than that of the controls 1.25±0.19 (p<0.05). These findings suggest that the efficacy of aldosterone antagonists in treating congestive heart failure may be in part through blocking the MRs, which are upregulated in the failing heart.
Outcomes and Prognostic Factors of Systolic as Compared With Diastolic Heart Failure in Urban America
Authors: McCullough Peter A. , Khandelwal Akshay K. , McKinnon John E. , Shenkman Heather J. , Pampati Vijayamalini , Nori David , Sullivan Roberta A. , Sandberg Keisha R. , Kaatz Scott
Published: February 2007

We sought to describe a large heart failure (HF) population with respect to systolic and diastolic abnormalities in terms of demographics, echocardiographic parameters, and survival. Using data abstracted from the Resource Utilization Among Congestive Heart Failure (REACH) study, a targeted subpopulation of 3471 patients had electrocardiographic, echocardiographic, and clinical data taken from automated sources during the first year of diagnosis. Among the HF population, 1811 (52.2%) had diastolic HF. Prevalence of diastolic HF trended with age, from 46.4% in those less than 45 years to 58.7% in those 85 years or older (p=0.001 for trend). Patients with diastolic HF had a higher mean ejection fraction (55.7% vs. 28.0%), lower left ventricular end‐systolic diameter (3.11 vs. 4.74 cm), and lower left atrium: aortic outlet ratio (1.28 vs. 1.38) (p=0.001 for each comparison). Annualized age, sex, and race‐adjusted mortality were 11.2% and 13.0% for those with diastolic and systolic HF, respectively (p=0.001). In a large, racially mixed, urban HF population, those with diastolic HF predominate and enjoy better‐adjusted survival than counterparts with systolic HF.
Brain Natriuretic Peptide and Diastolic Dysfunction in the Elderly: Influence of Gender
Authors: Roongsritong Chanwit , Qaddour Ahmad , Cox S. Lane , Labib Safaa , Bradley Charles A.
Published: February 2007

Diastolic heart failure is common in the elderly, particularly women. Previous studies on the value of brain natriuretic peptide in diastolic dysfunction have been largely limited to male subjects. The authors found that female gender, in addition to diastolic function, is an independent predictor of brain natriuretic peptide levels in the elderly without systolic ventricular dysfunction. The authors' data indicate that an optimal threshold of brain natriuretic peptide for detecting diastolic dysfunction should be qender‐specific.
Clinical and Hemodynamic Effects of Nesiritide (B‐Type Natriuretic Peptide) in Patients With Decompensated Heart Failure Receiving β Blockers
Authors: Abraham William T. , Cheng Mei L. , Smoluk Geraldine
Published: February 2007

The use of β blockers in congestive heart failure presents a therapeutic challenge for patients with acute episodes of decompensation. Such patients may be less responsive to positive inotropic agents, whereas the beneficial effects of nesiritide, which are not dependent on the β‐adrenergic receptor signal‐transduction pathway, may be preserved. This analysis of the Vasodilation in the Management of Acute CHF trial evaluated the safety and efficacy of nesiritide in decompensated congestive heart failure patients receiving β blockers. The Vasodilation in the Management of Acute CHF trial was a multicenter, randomized, controlled evaluation of nesiritide in 489 hospitalized patients with decompensated congestive heart failure. One hundred twenty‐three patients were on chronic β‐blocker therapy at enrollment (31 randomized to placebo, 50 to nesiritide, and 42 to nitroglycerin). Primary end points included pulmonary capillary wedge pressure and dyspnea evaluation at 3 hours. Patients receiving nesiritide, but not IV nitroglycerin, had significantly reduced pulmonary capillary wedge pressure vs. placebo at 3 hours regardless of β‐blocker use. The use of β blockers did not alter the beneficial effects of nesiritide on systemic blood pressure, heart rate, or dyspnea evaluation. In nesiritide‐treated subjects, safety profiles were similar regardless of β‐blocker use. Thus, the clinical and hemodynamic benefits and safety of nesiritide are preserved in decompensated congestive heart failure patients receiving chronic β blockade.
A Review of the Renal and Neurohormonal Effects of B‐Type Natriuretic Peptide
Authors: Burger Andrew J.
Published: February 2007

Adverse neurohormonal activation is an essential component in the pathogenesis of acute decompensated congestive heart failure (CHF). Consequently, blunting this activation is an important therapeutic goal. B‐type natriuretic peptide (BNP) is a counterregulatory hormone produced by the ventricles in response to pressure and volume load. Endogenous BNP levels are significantly elevated in patients with acute CHF, but these levels are frequently inadequate to overcome the excess neurohormonal activation present in this condition. Infusion of nesiritide, a recombinant form of endogenous human BNP, increases circulating BNP levels by several‐fold, augmenting the counterregulatory effects of this hormone. Clinical trials demonstrate that in patients with acute decompensated CHF, nesiritide produces arterial and venous vasodilation, reducing both preload and afterload; blunts adverse neurohormones, including renin, aldosterone, norepinephrine, and endothelin‐1; and improves renal hemodynamics and tubular function. As a result, nesiritide quickly reduces clinical symptoms and improves mortality in patients with acute CHF.
Effect of Orlistat in Obese Patients With Heart Failure: A Pilot Study
Authors: Beck‐da‐Silva Luís , Higginson Lyall , Fraser Margaret , Williams Kathryn , Haddad Haissam
Published: February 2007

Heart failure is the leading cause of hospitalization. Obesity is increasingly common and is a major public health problem. The aim of this study is to assess whether obese patients with heart failure can benefit from losing weight via an orlistat‐assisted diet. This randomized clinical trial included obese patients with ejection fractions ≤40%. Orlistat and diet counseling were compared with diet counseling alone. Twenty‐one consecutive obese patients with heart failure were recruited. Significant improvement in 6‐minute walk test (45.8 m; 95% confidence interval, 5.2–86.4 m; p=0.031), functional class (−0.6±0.5, p=0.014), weight loss (−8.55 kg; 95% confidence interval, −13.0 to −4.1 kg;p<0.001) and also significant decreases in total cholesterol (p=0.017), low‐density lipoprotein cholesterol (p=0.03), and triglycerides (p=0.036) were observed in the orlistat group. Orlistat can promote significant weight loss and symptoms of relief in obese patients with heart failure, as measured by 6‐minute walk test and functional capacity. The lipid profile improved. Orlistat was safe and well tolerated.
Emergency Department Observation of Heart Failure: Preliminary Analysis of Safety and Cost
Authors: Storrow Alan B. , Collins Sean P. , Lyons Michael S. , Wagoner Lynne E. , Gibler W. Brian , Lindsell Christopher J.
Published: February 2007

Emergency‐department (ED)‐based observation‐unit treatment has been shown to reduce inpatient admissions, hospital bed‐hours, and costs without adversely affecting outcomes for several conditions. A sequential group design study compared risk‐matched, acute decompensated heart failure patients admitted directly to the inpatient setting with those admitted to an ED observation unit for up to 23 hours before ED disposition. Outcomes were 30‐day readmissions or repeat ED visits for heart failure or 30‐day mortality. Estimates of bed‐hours and charges between the groups were compared. Sixty‐four patients were enrolled with 36 inpatient admissions and 28 observation unit patients. No patients died within 30 days. Observation unit patients had no significant difference in outcomes, a decrease in time from ED triage to discharge, a saving in mean bed‐hours, and less total charges. This pilot trial provides preliminary data that suggest admitted, low‐risk heart failure patients may be safely and cost‐effectively managed in an ED‐based observation unit. These findings need to be further evaluated in a randomized clinical trial.
Genetic Determinants of Vascular Oxidant Stress and Endothelial Dysfunction
Authors: Loscalzo Joseph , Voetsch Barbara , Liao Ronglih , Leopold Jane
Published: February 2007

Reactive oxygen species are products of cellular metabolism and function as normal signaling molecules in the vasculature. Overproduction of reactive oxygen species that outstrips antioxidant defenses generates oxidant stress that can lead to nitric oxide depletion and endothelial cell injury, and contributes to the pathophysiology of cardiovascular disease and myocardial dysfunction. Antioxidant enzymes that are important in limiting vascular oxidant stress include superoxide dismutases, catalase, glutathione peroxidases, and glucose‐6‐phosphate dehydrogenase. The relevance of deficiencies in glutathione peroxidase and glucose‐6‐phosphate dehydrogenase on endothelial and myocardial dysfunction will be reviewed.
Cardiac Unilateral Pulmonary Edema: Is It Really a Rare Presentation?
Authors: Hassan Walid , ElShaer Fayez , Fawzy Mohamed Eid , Helaly Sumaya Al , Hegazy Hesham , Akhras Nathem
Published: February 2007

Unilateral pulmonary edema is a distinctly unusual clinical entity that presents interesting and confusing diagnostic challenges. It is usually described as occurring with re‐expansion of a collapsed lung after rapid thoracocentesis of pleural air or pleural fluid. Unilateral pulmonary edema as an initial presenting manifestation for heart failure is uncommon and can be confused with other more common causes of alveolar or interstitial infiltrate, which can lead to a significant delay in treatment.
Heart Failure Drug Utilization Patterns for Medicaid Patients Before and After a Heart Failure‐Related Hospitalization
Authors: Howard Patricia A. , Shireman Theresa I.
Published: February 2007

The authors examined heart failure (HF) drug utilization patterns in Medicaid patients before and after a HF‐related hospitalization. This was a retrospective claims analysis of Kansas Medicaid beneficiaries hospitalized for HF between July 1, 2000, and March 31, 2001. HF drugs were tracked 6 months prior and 6 months following the admission. Angiotensin‐converting enzyme (ACE) inhibitor doses were compared with target ranges. The cohort of 135 patients had a mean age of 53.6 years and was predominantly female (66.7%) and Caucasian (70.4%) with a high prevalence of cardiovascular comorbidities. Before hospitalization, less than one third of patients were receiving ACE inhibitors, angiotensin receptor blockers, β blockers, digoxin, or vasodilators. Following hospitalization, increased utilization was observed for β blockers, digoxin, and angiotensin receptor blockers, but overall usage remained low. ACE inhibitors and vasodilator use remained constant. ACE‐inhibitor doses were below target ranges before and after hospitalization. In this Medicaid cohort, HF‐related hospitalizations did not lead to improved HF therapy.