bluuebunny/crossref_metadata_2025 huggingface dataset:
A Novel Design of a Noncylindric Stent With Beneficial Effects on Flow Characteristics: An Experimental and Numerical Flow Study in an Axisymmetric Arterial Model With Sequential Mild Stenoses
Authors: Papaioannou Theodore G. , Christofidis Charalambos Ch. , Mathioulakis Demetri S. , Stefanadis Christodoulos I.
Published: June 2007

Abstract:  The objective of this study was to investigate whether a novel noncylindric “stent,” implanted upstream of one or more mild arterial stenoses could be beneficial, by increasing in‐stent wall shear stresses (WSS) and by limiting the flow recirculation zones in the vicinity of the stenoses. An in vitro model employing flow visualization, and computational fluid dynamics were used for the study of steady and unsteady flow fields in a model of a coronary artery with two sequential 50% stenoses. Two different tube‐entrance geometries (a cylindric and a convergent nozzle), modeling an ostial stented arterial segment, were studied regarding their effect on flow patterns and WSS at various Reynolds numbers (Re = 200–800). In this preliminary study, the internal walls of these tube entrance geometries were smooth, not taking into account the roughness of the actual stent's strut. “In‐stent” WSS was significantly increased at the noncylindric configuration compared to that in the regular cylindric geometry. The difference of the spatially averaged “in‐stent” WSS between the two designs gradually increased with the increase in Re, reaching a peak value up to 50% in the case of the noncylindric endovascular device, for the examined Re range. For the same configuration, both the experimental and numerical analyses indicated a decrease in flow recirculation region at the vicinity distally to a sequential stenosis up to 6%, and the mean flow velocity was increased for both steady and pulsatile flow. These effects of the new “stent” configuration could be important for the delay of restenosis processes and should be further investigated in vivo.
The Influence of Hemodialysis on P‐Wave Signal‐Averaged Electrocardiogram Findings
Authors: Ozcan Turkay , Horoz Mehmet , Genctoy Gultekin , Uyar Bulent , Camsari Ahmet , Kiykim Ahmet A.
Published: June 2007

Abstract:  The role of P‐wave signal‐averaged electrocardiography (P‐SAECG) in the prediction of atrial fibrillation (AF) attacks has been validated in various disease states. In the present study, we aimed to investigate the effect of hemodialysis (HD) on P‐SAECG parameters and to determine the related risk factors that might affect those parameters. Ninety‐one HD patients and 68 controls were included. Hemoglobin levels, serum electrolytes, arterial pH, and interdialytic weight changes were assessed. P‐wave duration (PWD) and late potentials of P wave (root‐mean‐square voltage for the last 20 ms of the signal‐averaged P wave [LP20]) were determined by P‐SAECG. Pre‐ and postdialysis PWDs were significantly increased in HD patients than in controls (both P < 0.05), while the voltages of pre‐ and postdialysis LP20 were significantly reduced (both P < 0.05). A significant increase in PWD (P < 0.05) and a significant decrease in LP20 (P < 0.05) were observed following HD. Pre‐ and postdialysis PWDs and LP20 were correlated with age (all P < 0.05), dialysis duration (all P < 0.05), and left atrial diameters (LADs) (pre‐ and postdialysis) (all P < 0.05). Intradialytic changes in serum potassium levels were only correlated with postdialysis PWD and LP20 in HD patients (both P < 0.05). HD seems to increase PWD and to reduce LP20. Advanced age, duration of HD, intradialytic change in serum potassium levels, and LAD seem to be the important associates of P‐SAECG parameters in HD patients.
Construction and Performance of a Minibioreactor Suitable as Experimental Bioartificial Liver
Authors: Rodriguez Joaquín V. , Pizarro María Dolores , Scandizzi Angel L. , Guibert Edgardo E. , Almada Luciana L. , Mamprin María E.
Published: June 2007

Abstract:  This work deals with the construction and performance of a hollow fiber‐based minibioreactor (MBR). Due to its simple design and the utilization of standard materials, it could serve as a suitable tool to evaluate the behavior and performance of cold preserved or cultured hepatocytes in bioartificial liver devices. The system consists of 140 fiber capillaries through which goat blood is pumped at a flow of 9 mL/min. The cell compartment contains 90 × 106 rat hepatocytes (volume 10 mL) and an internal oxygenator made of silicone tubing. To test the in vitro function of the system, 2‐h perfusion experiments were performed, the evolution of hematocrit, plasma and extra‐fiber fluid osmolality, and plasma urea and creatinine concentrations were evaluated. The detoxication efficiency of an ammonia overload was tested, showing that the system has enough capacity to remove ammonium. Also, the MBR oxygen transfer capacity to hepatocytes was tested, showing that the cells received an adequate oxygen supply.
Perfluorocarbon Emulsions Cytotoxic Effects on Human Fibroblasts and Effect of Aging on Particle Size Distribution
Authors: Centis Valérie , Doillon Charles J. , Vermette Patrick
Published: June 2007

Abstract:  The purpose of this study was to characterize emulsion preparations made of perfluorooctyl bromide (PFOB) and egg yolk phospholipid (EYP) and their cytotoxicity. Dynamic light scattering and transmission electron microscopy revealed that freshly prepared emulsions stored at different temperatures for a 24‐h period have a unimodal particle size distribution with an average particle size of ca. 200 nm. The emulsion displayed a broader particle size distribution following a 14‐day storage. Primary human fibroblasts exposure to PFOB/EYP emulsions permanently inhibited cell proliferation and decreased mitochondrial activity. Scanning electron microscopy pictures reveal the presence of spherical particles on the fibroblasts following exposure to the emulsions after thorough rinsing with culture media.
Cadaver Fitting Study of the DexAide Right Ventricular Assist Device
Authors: Ootaki Yoshio , Ootaki Chiyo , Kamohara Keiji , Akiyama Masatoshi , Cingoz Faruk , Kopcak Michael W. , Dessoffy Raymond , Liu Jenny , Massiello Alex , Horvath David , Chen Ji‐Feng , Zhou Qun , Benefit Stephen , Golding Leonard A.R. , Fukamachi Kiyotaka
Published: June 2007

Abstract:  The DexAide right ventricular assist device (RVAD) has been developed to provide an implantable RVAD option to surgeons. The aim of this study was to determine the optimal cannula design and optimal implantation location of the DexAide RVAD in preparation for its clinical use. Separately, a HeartMate XVE left ventricular assist device (LVAD) and CorAide LVAD models were implanted into the preperitoneal and right thoracic space, and the anatomical fit of the DexAide RVAD was evaluated in five preserved human cadavers. The DexAide RVAD inflow cannula was inserted through the diaphragmatic surface of the right ventricle and the outflow was directed to the pulmonary artery. Right thoracic implantation of the DexAide RVAD provided an excellent fit with either the HeartMate or CorAide LVAD in all cadavers. The results of this study will guide improvements in the designs of cannulae and implantation of the DexAide RVAD in future clinical applications.
Angiotensin II Receptor Blockers in the Treatment of Heart Failure
Authors: Peterson Ross C. , Dunlap Mark E.
Published: June 2007

Heart failure treatment centers on antagonism of the renin‐angiotensin‐aldosterone system and adrenergic nervous system. Angiotensin‐converting enzyme (ACE) inhibitors have been shown to benefit patients with left ventricular systolic dysfunction irrespective of symptoms. Despite ACE inhibitor use, left ventricular dysfunction continues to progress in most patients. In addition, ACE inhibitors are substantially underused in patients who would benefit, in large part due to physician concern over potential adverse effects. Angiotensin receptor blockers (ARBs) have been proposed as either potential substitutes for ACE inhibitors or as additive therapy for heart failure patients. The authors will review the importance of the renin‐angiotensin‐aldosterone system in the progression of heart failure, as well as the mechanisms by which ACE inhibitors and ARBs counteract this effect. The clinical evidence to date supporting the use of ARBs in heart failure also will be reviewed. Based on current trials, ARBs are suitable substitutes for ACE inhibitors in patients who have true ACE inhibitor intolerance, but ACE inhibitors should still be considered first‐line therapy in the treatment of left ventricular systolic dysfunction and heart failure. ARBs are a reasonable additive therapy in patients on maximal ACE inhibitor therapy who remain symptomatic, especially in patients unable to tolerate β blockade.
Epidemiology of Congestive Heart Failure in Three Ethnic Groups
Authors: Demirovic Jasenka , Prineas Ronald , Rudolph Mark
Published: June 2007

Congestive heart failure (CHF) is a leading cause of morbidity, disability, and mortality in old age, but little is known about the epidemiology of this condition in free‐living minority populations. To determine the prevalence of CHF and associated risk factors in a multiethnic community, a population sample of 2759 elderly (i.e., 65 years of age and older) African American (AA), Hispanic‐Cuban (HC), and white non‐Hispanic (WNH) men and women from Miami‐Dade County, Florida, were examined. There were 153 (5.6%) cases of self‐reported CHF in the sample. The unadjusted prevalence rate of CHF was virtually identical among elderly AA (4.8%) and WNH (4.9%) but was significantly (p=0.04) lower than the rate among HC (6.8%). Sex‐ and ethnic‐specific analyses showed that the highest prevalence rate of CHF was among HC women (8.2%). A multiple logistic analysis was used to calculate the odds ratio (OR) and 95% confidence interval (CI) of CHF in relation to age, sex, ethnicity, medical history, and smoking and alcohol drinking habits. Age (65–74 vs. 75–84, OR 1.7, CI 1.2–2.4, p=0.01), HC ethnic group (OR 1.5, CI 1.0–2.4, p=0.05), history of hypertension (OR 1.5, CI 1.1–2.1, p=0.02), history of myocardial infarction (OR 2.3, CI 1.5–3.5, p=0.0001), and history of diabetes mellitus (OR 1.9, CI 1.3–2.8, p=0.001) were directly, significantly, and independently associated with the prevalence of self‐reported CHF. The findings here confirm those of prior studies in elderly white U.S. residents, which indicate that heart attack, hypertension, and diabetes mellitus are major risk factors for CHF. The results also show that elderly AA and WNH have similar CHF prevalence rates. The higher CHF prevalence in elderly HC women found in this study requires further investigation.
Nesiritide (hbNP): A New Class of Therapeutic Peptide for the Treatment of Decompensated Congestive Heart Failure
Authors: Katz Stuart D.
Published: June 2007

Natriuretic peptides are a family of endogenous peptide hormones with vasodilating, natriuretic, diuretic, and lusitropic properties. Administration of pharmacologic doses of exogenous natriuretic peptides may provide therapeutic benefit in patients with chronic heart failure. In controlled clinical trials, short‐term administration of nesiritide (human brain natriuretic peptide) to patients with heart failure is associated with improved resting hemodynamics, modest increases in sodium excretion, evidence of suppression of neurohormonal activation, and improvements in symptoms of heart failure. Additional trials to determine the clinical efficacy and safety of nesiritide are warranted.
Peripartum Cardiomyopathy: Case Report and Literature Review
Authors: Skaluba Stanislaw J. , Berkson David M.
Published: June 2007

Peripartum cardiomyopathy is an unusual and uncommon form of dilated cardiomyopathy that is often fatal to young women. Fetal outcome, however, is quite good. The disease occurs in 250–1350 women each year in the United States. Myocarditis of viral, immunologic, or idiopathic etiology has been suggested. Diagnostic findings are consistent with congestive heart failure. Primary therapy consists of bed rest, sodium and fluid restriction, vasodilators, digoxin, and diuretics. Refractory cases can be treated with cardiac transplantation. Selected patients require anticoagulation. Prognosis depends on 6‐month recovery of left ventricular function. It is important to emphasize that functional recovery does not denote total recovery of cardiac function; this is critical in terms of future pregnancies. This article presents the case of a young woman with peripartum cardiomyopathy and a review of the literature.
Raison d'Être Behind ACE Inhibitors and AT1 Receptor Combinations in Chronic Heart Failure: Chemical Nuances or Clinical Significance?
Authors: Ali Omar , Ventura Hector O.
Published: June 2007

The following case description serves to illustrate the difficulties often faced in clinical practice in implementing what appear to be fairly simple and clear evidence‐based guidelines regarding angiotensin‐converting enzyme (ACE) inhibitors and no clear guidelines regarding angiotensin receptor blocker (ARB) use or, more importantly, ACE inhibitor and ARB combinations in chronic heart failure.
Hyperkalemia in Congestive Heart Failure
Authors: Gehr Todd W.B. , Sica Domenic A.
Published: June 2007

Hyperkalemia is not an uncommon occurrence in the congestive heart failure patient, particularly when renal failure coexists. Hyperkalemia in CHF is typically medication‐related. Its occurrence is inevitably linked to the simultaneous ingestion of angiotensin‐converting enzyme inhibitors and β‐blockers, and more recently, aldosterone receptor antagonists, such as spironolactone. The most devastating consequence of hyperkalemia is its cardiotoxicity that can be fairly insidious in its rate of development. The therapy of hyperkalemia in congestive heart failure can involve both acute and semiacute management phases. Acute hyperkalemia management includes measures that block the adverse membrane effects of hyperkalemia, such as intravenous calcium administration, and efforts to shift potassium intracellularly, such as occurs with intravenous bicarbonate and/or inhaled β‐agonists. Semiacute management of hyperkalemia includes measures to increase urinary potassium excretion and administration of binding resins, such as Kayexalate®. Prevention is the cornerstone of hyperkalemia management in the heart failure patient and requires that careful attention be directed to both identifying exogenous sources of potassium and pinpointing the maximum tolerable dose of either an angiotensin‐converting enzyme inhibitor or an angiotensin‐receptor blocker.
Evaluation and Management of Acutely Decompensated Chronic Heart Failure in the Emergency Department
Authors: Kosowsky Joshua , Abraham William T. , Storrow Alan
Published: June 2007

A wide range of patients with symptomatic heart failure seek treatment in the emergency department. While there is no single approach to the diversity of patients with acutely decompensated heart failure, certain overarching principles apply. For patients with acute pulmonary edema or cardiogenic shock, the first priority must be rapid stabilization and treatment of reversible problems. For patients with less dramatic presentations, a more systematic search for precipitating factors may be required. Therapy, in general, is directed at reversing dyspnea and/or hypoxemia caused by pulmonary edema, improving systemic perfusion, and reducing myocardial oxygen demand. While morphine and diuretics still have their traditional roles, vasodilators and inotropic agents play an increasingly important part in the modern pharmacologic approach to decompensated heart failure in the emergency department. After evaluation and stabilization in the emergency department, most patients will require hospital admission, although a subset of low‐risk patients may be appropriate for discharge to home following a period of observation. Strategies to optimize emergency department care are likely to have an impact upon patient outcomes and upon resource utilization.
Trastuzumab Therapy and the Heart: Palliation at What Cost?
Authors: Aikat Shamik , Francis Gary S.
Published: June 2007

Trastuzumab (Herceptin®), a monoclonal HER2 receptor blocker, was approved by the Food and Drug Administration in September, 1998 for the treatment of advanced breast carcinoma. It is rapidly emerging as an important drug for the treatment of metastatic breast cancer. The results of a pivotal trial revealed a 53% improvement in the response rate when trastuzumab was added to the standard chemotherapeutic regimen. However, a greater than fourfold increase in the occurrence of congestive heart failure was also noted. This novel agent has ushered in hope for thousands of women, but its use mandates that a clear understanding of its effects and relative risks be appreciated. Careful patient selection for the use of trastuzumab is critically important. It is prudent that cardiologists be aware of its cardiotoxicity, and that the risk/benefit ratio be clarified before its use in less invasive forms of breast cancer.
Cardiac Resynchronization: A Novel Therapy for Heart Failure
Authors: Wong Kar‐Lai , Kocovic Dusan Z. , Loh Evan
Published: June 2007

Despite advances in medical therapy for patients with congestive heart failure, morbidity and mortality remain high. Conduction abnormalities, such as left bundle branch block, right bundle branch block, and nonspecific conduction delay, are observed commonly in patients with dilated cardiomyopathy. In patients with heart failure, the presence of intraventricular conduction delay is associated with more severe mitral regurgitation and worsened left ventricular systolic and diastolic function, and is an independent risk factor for increased mortality. Conventional dual‐chamber (right atrial and right ventricular) pacing with a short atrioventricular delay was initially introduced as therapy for patients with advanced congestive heart failure to improve diastolic dysfunction and reduce mitral regurgitation. The acute beneficial hemodynamics effects observed in early, uncontrolled studies were not confirmed in subsequent randomized, controlled studies with longer follow‐up. Cardiac resynchronization with novel biventricular (left and right ventricular) pacing systems has resulted in hemodynamics and functional benefits in patients with congestive heart failure and an underlying intraventricular conduction delay. Improvements in cardiac index, systolic blood pressure, and functional class have been reported with biventricular pacing, both acutely and at >1 year of follow‐up. These encouraging preliminary results with biventricular pacing in patients with congestive heart failure will be validated in two prospective, randomized, controlled trials, Multicenter InSync Randomized Clinical Evaluation (MIRACLE) and Comparison of Medical Therapy, Pacing, and Defibrillation in Chronic Heart Failure (COMPANION). These studies are designed to evaluate the long‐term efficacy of biventricular pacing in improving exercise capacity and in reducing morbidity and mortality in patients with advanced, symptomatic congestive heart failure.
Using the Transtheoretical Approach to Facilitate Change in the Heart Failure Population
Authors: Suppan Jacqueline
Published: June 2007

Heart failure is a significant health problem that requires a multidisciplinary approach for successful intervention. Five million Americans currently suffer from heart failure, resulting in an annual expenditure estimated at $20–$40 billion. However, with early identification and intervention, the progression of heart failure can be stopped. Change in lifestyle and adherence to a prescribed plan of care recommended for heart failure treatment can lead to improved quality of life. The Transtheoretical Model provides a framework for facilitating the behavioral changes necessary for the optimal treatment of heart failure. Future research is suggested to evaluate outcomes of behavioral changes in heart failure populations upon implementation of this model.
Profiles of Quality Improvements in Heart Failure Care
Authors: Delaney Richard J. , Havranek Edward P. , Ordin Diana L. , Taylor Jane P.
Published: June 2007

The Health Care Financing Administration, with its National Heart Failure project, has made heart failure care one of its targets for quality improvement. Previous columns have highlighted the clinical and epidemiologic background for the National Heart Failure project. This column provides “real‐world” examples of hospitals improving care for their heart failure patients.
Angiotensin‐Converting Enzyme Inhibitors and Angiotensin Receptor Blockers in Congestive Heart Failure: Do They Differ in Their Renal Effects in Man?
Authors: Sica Domenic A.
Published: June 2007

Angiotensin‐converting enzyme (ACE) inhibitors are used in the management of a wide range of cardiovascular conditions, including congestive heart failure (CHF). Although the experimental evidence in support of their use in CHF is incontrovertible, their pattern of usage has failed to keep pace with the research findings. One factor that has fueled the hesitancy to use ACE inhibitors in CHF has been the concern that renal function might worsen upon their receipt. Although the glomerular filtration rate may decline when ACE inhibitor or angiotension receptor blocker therapy is started in CHF, in most cases it is not a reason to discontinue therapy other than temporarily. Although ACE inhibitors and angiotensin receptor blockers may differ theoretically in their renal effects, published information to date has not shown such a difference.
Heart Failure in β‐Thalassemia
Authors: Kremastinos Dimitrios Th.
Published: June 2007

Heart failure remains the main cause of death in β‐thalassemia despite the progress that has been made. Myocardial iron deposition alone does not affect left ventricular relaxation but directly causes left ventricular myocardial restriction with considerably elevated pulmonary pressure. This leads to symptoms and signs of predominantly right‐sided heart failure, which is usually observed in elderly and severely hemosiderotic populations. Left ventricular systolic dysfunction and failure, which occurs in younger, less hemosiderotic populations, seems to be multifactorial in etiology. Apart from iron loading, immunogenetic risk factors trigger the mechanisms of left‐sided heart failure development in the context of dilated‐type cardiomyopathy.
Left Atrial Overload Can Be Used to Estimate Mitral Regurgitant Volume
Authors: Cicoira Mariantonietta , Rossi Andrea , Golia Giorgio , Gasparini Giampaolo , Anselmi Maurizio , Zardini Piero
Published: June 2007

This study was conducted to assess the accuracy of the estimated mitral regurgitant volume using both the left atrial filling volume and the systolic component of pulmonary vein flow expressed as the percent of its total. Since mitral regurgitation fills the left atrial chamber, the variation in atrial volume during ventricular systole has been proposed as a means to evaluate the severity of regurgitation. Although the correlation with invasive grading of mitral regurgitation is good, there is an unacceptable overlap among grades caused by the absence of information concerning pulmonary vein flow, which enters the left atrium while regurgitation occurs. The Doppler regurgitant volume, or Dp‐RVol (mitral stroke volume minus aortic stroke volume) was quantified in 74 patients with any degree and etiology of mitral regurgitation. Atrial volumes were measured from the four‐chamber apical view (biplane arealength method). The systolic time‐velocity integral of pulmonary vein flow was expressed as the percent of the total (PVs%) (systolic‐diastolic) time‐velocity integral. These parameters were subjected to multivariate analysis and a regression equation was obtained. The equation was subsequently applied to a group of 31 patients without mitral regurgitation, as evaluated by color Doppler or continuous‐wave Doppler and to the overall population (105 patients) in order to estimate the mitral regurgitant volume. In 74 patients with mitral regurgitation, the Doppler regurgitant volume was univariately correlated with the left atrial filling volume, (r=0.74; p<0.0001) and the systolic pulmonary vein velocity integral expressed as the percent of the total (r=0.67; p<0.0001). In multiple regression analysis, the combination of atrial filling and the pulmonary vein velocity integral provided the more accurate estimation of the regurgitant volume (R2=0.84; standard error of the estimate [SEE], 13.9 mL; p<0.0001; Dp‐RVol = 7.84+[1.08*left atrial filling volume] − [0.839*PVs%]). In 31 patients with no mitral regurgitation detected by color Doppler or continuous wave Doppler the estimated regurgitant volume was 4.3±6.6 mL. In the overall population the estimated regurgitant volume and the Doppler regurgitant volume correlated well with each other (R2=0.85; SEE, 11.5 mL; p<0.0001). The equation was 100% sensitive and 98% specific in detecting a regurgitant volume higher than 55 mL. The combination of the atrial filling volume and the systolic pulmonary vein time‐velocity integral expressed as the percent of the total allows reliable estimation of the regurgitant volume in patients with mitral regurgitation.
Prematurely Terminated Clinical Trials and Their Application to Cardiovascular Medicine
Authors: Sica Domenic A.
Published: June 2007

Controlled clinical trials in cardiovascular disease remain the cornerstone of field‐specific therapeutic advances. Since the introduction of the concept of controlled clinical trials, there has been considerable fine‐tuning of the design, conduct, and analysis of such studies. A growing awareness of ethical issues emerging from such trials has led to increased public and investigator scrutiny and the routine requirement for both interim data analysis and full conflict‐of‐interest disclosure. A be stopped if the observed findings warrant early termination. For example, highly positive findings, as were noted in the HOPE Study (Heart Outcomes Prevention Evaluation), led to its closure after 4.5 years of treatment, which was 1 year earlier than anticipated. Also, the doxazosin treatment limb of ALLHAT (Antihypertensive and Lipid‐Lowering Treatment to Prevent Heart Attack Trial) and the amlodipine treatment limb of AASK (African American Study of Kidney Disease and Hypertension)were stopped early, because of negative findings in one of their treatment limbs. Finally, economic considerations can enter into the decision to close a study early, as was the case in the CONVINCE (Controlled‐Onset Verapamil Investigation of Cardiovascular Endpoints)trial. Most such decisions rely heavily on information obtained from independent data and safety monitoring boards. Such boards ensure patient safety by providing an unbiased, ongoing review of data, which would otherwise be unavailable until a study's completion. Early termination of a clinical trial can have important clinical and economic implications and, in particular, can substantially redirect the pattern of clinical practice.
Angiotensin II and Thirst: Therapeutic Considerations
Authors: Sica Domenic A.
Published: June 2007

Angiotensin II is the effector peptide of the renin‐angiotensin system and is involved in a wide range of physiologic functions that relate to volume control. In this regard, angiotensin II maintains and regulates salt and water balance, is critically involved in cardiovascular function, and governs thirst. When present in excess, angiotensin II can pathologically influence each of these functions. The role of angiotensin II in controlling sodium balance, in both renal insufficiency states and congestive heart failure, is clearly recognized. Alternatively, it is poorly appreciated that angiotensin II plays an important role in both normal and pathologic thirst states. The latter is a potential problem in both end‐stage renal disease and congestive heart failure. Angiotensin‐converting enzyme (ACE) inhibitors and angiotensin receptor antagonists (AT1‐RAs) have both been shown to reduce abnormal thirst drive. Whether an ACE inhibitor or an AT1‐RA lessens thirst drive to any significant degree relates to its capacity to penetrate the blood‐brain barrier. Head‐to‐head comparisons of ACE inhibitors and AT1‐RAs, as to their effect on thirst drive, have not been undertaken in a systematic fashion; thus, until otherwise established, the effect of these compounds on thirst should be viewed as a class effect, albeit one that is likely to be dosedependent.
Monitoring of Quality of Life in Congestive Heart Failure Populations
Authors: Berlin Richard B. , Schatz Bruce R.
Published: June 2007

The health care system has traditionally focused on treating disease at the point of failure, such as life‐saving surgery or intensive medical therapy. As demographics shift more to an aging population, management of health‐related quality of life and life‐restricting disease becomes more necessary. Prominent among such diseases is congestive heart failure, which must be addressed as a major chronic health condition with its consequent effect on quality of life. This paper examines the methods of monitoring the quality of life in congestive heart failure. Particular attention is paid to congestive heart failure‐related questionnaires to derive lifestyle information directly from patients. Comparison is made with general quality of life instruments. Most commonly, these questionnaires are applied to small populations in limited situations. New technology, such as the Internet, has greatly expanded the breadth and depth of health monitors by tracking status directly in patients' homes. This promises new levels of population management for heart disease.
Value of Dobutamine Echocardiography for the Assessment of Myocardial Viability for Revascularization
Authors: Senior Roxy , Lahiri Avijit
Published: June 2007

Coronary artery disease accounts for a majority of heart failure cases in the western world. Many cardiologists believe that abnormal regional contractions in patients with coronary artery disease is equivalent to irreversibly damaged myocardium. Studies now challenge this long‐held assumption. Data exist regarding the value of assessing myocardial viability in those patients with severe left ventricular dysfunction and coronary artery disease. This report discusses dobutamine echocardiography as a technique for assessing myocardial viability and for selecting patients for revascularization.
Reversible Cardiomyopathy Due to Atrial Fibrillation in a 46‐Year‐Old Patient
Authors: Aslam Mohammad Shakil , Brookfield Leslie
Published: June 2007

The authors describe the challenging case of a 46‐year‐old patient who presented with a 2‐week history of exertional dyspnea, paroxysmal nocturnal dyspnea, and orthopnea. He was found to have left ventricular failure and atrial fibrillation with a rapid ventricular rate. Initial work‐up revealed dilated cardiomyopathy with marked left ventricular dysfunction, without any obvious cause. He received standard medical therapy for left ventricular dysfunction and his symptoms improved. Electrical cardioversion to sinus rhythm and maintenance resulted in complete recovery of left ventricular function within 6 months.
When Cancer and Heart Failure Cross Paths: A Case Report of Severe Cardiorenal Compromise Associated with the Anti‐CD20 Monoclonal Antibody Rituximab in a Patient with Dilated Cardiomyopathy
Authors: Nikolaidis Lazaros A.
Published: June 2007

The authors describe the case of a 41‐year‐old man with end‐stage, nonischemic dilated cardiomyopathy of 11 years' duration. The patient had been deemed ineligible for transplantation, despite his young age, when he was diagnosed with non‐Hodgkin's lymphoma 7 years previously. Since he had survived the lymphoma without significant chemotherapy, while his cardiovascular and renal status continued to deteriorate, the issue was revisited. In an attempt to at least render him eligible for an assist device, a novel, promising, and reportedly nontoxic immunomodulation therapy for his lymphoma was employed. This consisted of infusion of the monoclonal antibody rituximab, specifically targeting the CD20 antigen on B cells. Despite testimonials concerning the benign nature of the treatment, the patient was unable to tolerate it and his clinical condition deteriorated rapidly, eventually leading to his death. The authors discuss potential mechanisms that might have accounted for the patient's cardiorenal compromise, with a focus on a very rare “cytokine release” syndrome attributed to this type of monoclonal antibody therapy and the probable interplay of cytokines in advanced heart failure.
High‐Output Cardiac Failure in a Patient with Prostate Cancer
Authors: Greci Laura S. , Rashkow Andrew
Published: June 2007

The authors describe a case of high‐output cardiac failure in a patient with rapidly progressing prostate cancer for which no previously described cause could be found. His new onset and increasingly worsening heart failure corresponded to the rapid spread of his prostate cancer. The authors hypothesize that a cytokine released from the neoplastic cells or the bone was responsible for the high‐output cardiac failure observed in this patient.
Propionic Acidemia: A Rare Cause of Cardiomyopathy
Authors: Bhan Adarsh K. , Brody Cheryl
Published: June 2007

The symptoms of propionic acidemia, an autosomal recessive disorder involving deficiency of the enzyme propionyl‐coenzyme A carboxylase, are highly varied and may present at any time in the patient's life. Cardiomyopathy, a rare complication of this disorder, has been reported in only a small number of pediatric patients. The authors describe a case of adult‐onset cardiomyopathy in a 23‐year‐old female with propionic acidemia diagnosed in early childhood and associated with multiple longstanding comorbidities. The possible mechanisms of propionic acidemia‐associated cardiomyopathy, and the importance of early recognition and appropriate management, are discussed.
Atrial Fibrillation in Patients with Heart Failure: Pharmacologic Options
Authors: Matalka Mazen S. , Deedwania Prakash C.
Published: June 2007

Atrial fibrillation is a common arrhythmia in patients with heart failure. The presence of atrial fibrillation deteriorates cardiac function and increases the risk of thromboembolic events. The management of patients with atrial fibrillation in association with heart failure should consist of ventricular rate control, prevention of thromboembolic events, and conversion to normal sinus rhythm. Traditionally, digoxin has been widely used in patients with heart failure and atrial fibrillation; however, it does very little to restore sinus rhythm and requires the addition of another rate‐limiting agent to control ventricular rate. The likelihood of successful cardioversion is dependent on the duration of heart failure and the degree of neurohormonal activation. The initiation of antiarrhythmic drug therapy in patients with heart failure should be guided by safety issues as well as consideration of potential benefits vs. risks associated with therapy. Amioarone has been evaluated in numerous clinical trials and appears to be safe and effective when used in low dosage. Treatment with dofetilide is another option. Comparative studies with oral dofetilide vs. amiodarone are needed to evaluate their efficacy in restoration and maintenance of sinus rhythm in patients with heart failure. Such trials will clearly define the role of dofetilide in the treatment of atrial fibrillation. Routine prophylactic use of antiarrhythmic drug therapy for chronic atrial fibrillation in the setting of heart failure is not recommended due to a low efficacy rate and high proarrhythmic risk. Anticoagulation with warfarin and rate control remain the standard therapy.
Use of a Clinical Care Map for the Management of Congestive Heart Failure in a Community Hospital
Authors: Lanzieri Mark , Hobbs Richard , Roy Patricia , Richmond Roberta
Published: June 2007

Background. Managed care rewards those individuals and institutions capable of achieving superior patient outcomes while making wise use of limited resources. However, studies of patient outcomes under these circumstances are lacking. We sought to investigate whether decreasing length of stay and limiting resource utilization had a negative effect on objective measurements of patient outcome for patients with congestive heart failure. Methods. Guided by studies of evidence‐based medicine, a multidisciplinary team developed and implemented a clinical care multidisciplinary action plan for the inpatient management of congestive heart failure. This provided practitioners with a target length of hospital stay, projections for daily improvements based on intervention, guidelines for diagnostic studies and medical therapy, early identification of patients with special discharge needs, and intensive patient education. Results. Shorter lengths of stay for patients with congestive heart failure were achieved without negatively impacting on mortality or readmission rates. The study found a trend in favor of greater utilization of appropriate medical therapy despite shorter hospitalization. Conclusion. The use of a clinical care map for management of complex medical illnesses can be associated with shorter hospital stay without sacrificing patient outcomes.
Nonadherence with ACE Inhibitors Is Common and Can Be Detected in Clinical Practice by Routine Serum ACE Activity
Authors: Struthers Allan D. , Anderson Gillian , MacFadyen Robert J. , Fraser Callum , MacDonald Thomas M.
Published: June 2007

Our objective was to assess whether serum angiotensin‐converting enzyme (ACE) activity during routine clinical practice accurately reflects patient adherence to ACE inhibitor treatment in chronic heart failure (CHF). During 1994–95, ACE was measured in 73 CHF patients who were routinely attending the heart failure clinic at Ninewells Hospital. At the same time, the Medicines Monitoring Unit collected data on whether and when prescriptions for ACE inhibitors were redeemed at community pharmacies, which enabled each patient's adherence over a prolonged period to be assessed. We then correlated whether an elevation in serum ACE was associated with poor adherence with ACE inhibitor treatment. In total, 18% of CHF patients appeared to exhibit <70% adherence with their ACE inhibitor treatment, with 34% exhibiting <85% adherence and 58% exhibiting <100% adherence. A serum ACE activity of >12 U/L gave 91 % positive predictive accuracy that the patient was <100% adherent with his or her ACE inhibitor treatment. At the other extreme, a serum ACE <6.5 U/L gave 81% positive predictive accuracy that the patient was >85% adherent with ACE inhibitor treatment. Nonadherence with ACE inhibitor treatment, therefore, was found to be common in patients with CHF. The simple, inexpensive test of serum ACE activity can be used in CHF patients to identify many, although not all, nonadherent patients so that adherence‐enhancing strategies can be targeted toward them. Further work is clearly required to explore the precise clinical utility of this promising test.
Patient Perceptions of Quality of Life and Treatment in an Outpatient Congestive Heart Failure Clinic
Authors: Paul Sara , Sneed Nancee
Published: June 2007

In an effort to better understand patients' definitions of quality of life (QOL) and to determine which tools would be most appropriate for use in future studies, a descriptive study was done in a university‐based congestive heart failure clinic. Participants were asked a series of five open‐ended questions regarding their perceptions of QOL during recorded interviews. Most patients equated QOL with the ability to perform physical functions in the same way they did before developing heart failure. They grieved for their former abilities and expressed lower self‐esteem due to loss of independence from physical limitations. The Short Form‐36 and the Minnesota Living With Heart Failure Questionnaire addressed the QOL issues important to our patients. It is important for health care providers to consider the patient's perception of QOL when using quantitative tools for QOL measurement in clinical practice.
Alcoholic Cardiomyopathy: Is It Dose‐Dependent?
Authors: Lee William K. , Regan Timothy J.
Published: June 2007

Alcohol is a known myocardial depressant. In a dose‐dependent fashion, one can show progressive decline in left ventricular systolic function. This observation has been used to implicate alcohol as a major cause of up to 30% of all dilated cardiomyopathies. However, it is not well recognized that there appears to be a biphasic cardiovascular effect based on the chronic dose of alcohol ingested. At low to moderate doses, studies suggest that alcohol has a favorable impact on cardiovascular outcomes. In other words, patients who have one to two glasses of alcohol per day have fewer myocardial infarctions and an improved survival. Large trials, such as the Physician Health Study, indicate that this benefit may be over wide ranges of doses, from one to seven glasses per week. When this is looked at in higher‐risk diabetic patients, the benefit of low to moderate doses of alcohol persists. Together, this information suggests that low to moderate doses of alcohol improve cardiovascular risk, and this benefit may exceed the risk of hypertension or heart failure. It is equally important to recognize the serious down side to alcohol ingestion. At chronic high‐dose intake of alcohol, there is a direct relationship to elevated blood pressure. Also, prolonged exposure to alcohol increases the likelihood of developing congestive heart failure. Combining the negative cardiovascular effects with potential danger to other organs, such as the liver, underscores the risk for high‐dose alcohol. Therefore, there is a biphasic dose response to alcohol. At low to moderate doses, patients experience an overall cardiovascular benefit; it is only when a critical threshold is reached by high‐dose alcohol that one observes the toxic effects. Patients on low to moderate ingestion of alcohol should be reassured, but those on high doses should be strongly encouraged to abstain due to potential toxic effects of alcohol.
Enhanced External Counterpulsation as Treatment for Chronic Angina in Patients With Left Ventricular Dysfunction: A Report From the International EECP Patient Registry (IEPR)
Authors: Soran Ozlem , Kennard Elizabeth D. , Kelsey Sheryl F. , Holubkov Richard , Strobeck John , Feldman Arthur M.
Published: June 2007

The International Enhanced External Counterpulsation (EECP) Patient Registry tracks acute and long‐term outcome for consecutive patients treated for chronic angina. Although EECP has previously been shown to be a safe and effective treatment for angina, little information is available on its use in patients with left ventricular (LV) dysfunction. This report compares the acute outcome and 6‐month follow‐up for a group of patients with severe LV dysfunction and a group of patients without LV dysfunction. Of 1402 patients in the registry recruited in 1998–1999 who had recorded values of LV ejection fraction (LVEF) at baseline, 1090 (77.7%) had preserved LV function (LVEF >35%) and 312 (22.3%) had LV dysfunction (LVEF ≤35%). Six‐month follow‐up was available on 84% of these patients. Pre‐EECP patients with LV dysfunction had a longer history of coronary artery disease (12.9 years vs. 9.1 years; p<0.001), a higher rate of congestive heart failure (60.6% vs. 20.1% p<0.001) and myocardial infarction (83.5% vs. 61.9% p<0.001). Patients with LV dysfunction had more severe pre‐EECP angina, with 86.2% presenting with Canadian Cardiovascular Society Class III/IV vs. 73.6% p<0.01. Patients with LV dysfunction, consistent with their more severe baseline profile, suffered more adverse events (death, unstable angina, and exacerbation of heart failure) during the treatment period and were less likely to complete the full course. Immediately post‐EECP, angina decreased by at least one class in 67.8% of patients with LV dysfunction (vs. 76.2% p<0.01), and 35.9% of LV dysfunction patients vs. 39.0% had discontinued nitroglycerin use (p=NS). At 6‐month follow‐up, patients with LV dysfunction showed higher rates of death (9.3% vs. 2.2% p<0.001) and exacerbation of congestive heart failure (9.9% vs. 3.7% p<0.001). Rates of the composite outcome of death/myocardial infarction/coronary artery bypass grafting/percutaneous coronary intervention (15.4% vs. 8.3% p<0.001) were also higher for patients with LV dysfunction. However, patients not reporting such an event showed maintenance of their improved anginal status, with 81% of LV dysfunction vs. 83.8% of patients without LV dysfunction (p=NS) reporting angina at 6 months equal to or less severe than immediately post‐EECP, and nitroglycerin use was still reduced at 46.1% for LV dysfunction vs. 37.4% (p<0.05). The rate of event‐free angina maintenance at 6 months was 67.0% for patients with LV dysfunction and 70.6% of patients with preserved LV function (p=NS). Patients with LV dysfunction achieved a less robust reduction in angina than did those without LV dysfunction. For the majority of the patients in the registry, this reduction was maintained at 6 months.
Cellular Cardiomyoplasty—A Novel Approach to Treat Heart Disease
Authors: Müller‐Ehmsen Jochen , Kedes Laurence H. , Schwinger Robert H.G. , Kloner Robert A.
Published: June 2007

Cell transplantation is a novel experimental strategy to treat heart disease, such as myocardial infarction and heart failure. Its beneficial effects may include active contribution of transplanted cells to contractile function, passive improvement of the mechanics of the heart, induction of neoangiogenesis or other indirect influences on the biology of the heart. Several cell types have been used for cardiac cell transplantation including cardiac cells from fetal or newborn animals and cardiac muscle cell lines, skeletal myoblasts and skeletal muscle cell lines, smooth muscle cells, and a variety of stem cells, either adult or embryonic. With many of these cells, encouraging results in experimental ischemic and nonischemic heart disease have been obtained including successful cell survival after transplantation, integration into the host myocardium, and improvement of the function of diseased hearts. Most of these studies found cardiac contractility improved and some found enhanced angiogenesis. However, the mechanisms of these effects remain obscure, and the impact of dosage (cell number) on functional response is completely unclear. In addition, not enough comparative studies were performed to allow preference of one cell type over the other. The current data suggest that whatever cell species is used, the best survival and integration may be accomplished if immature and undifferentiated cells are used. Any kind of stem cell has obvious advantages in terms of endless reproducibility and plasticity, but the complete differentiation and maturation into cardiac myocytes still needs to be proven. At present several clinical studies are exploring the therapeutic benefits of cellular cardiomyoplasty in patients with ischemic heart disease, but it has to be noted that there are many issues that need to be addressed before this strategy will add to the therapeutic options for patients with heart disease.
The Nitric Oxide Pathway and Oxidative Stress in Heart Failure
Authors: Searles Charles D.
Published: June 2007

Chronic heart failure is associated with pathophysiologic alterations in myocardial and vascular function. Accompanying these changes are increased oxidative stress and modulation of the nitric oxide pathway. The role of the nitric oxide pathway in heart failure and the effect of its interaction with reactive oxygen species are complex, with diverse pathophysiologic implications in both the heart and the peripheral vasculature. This review discusses current information regarding the nitric oxide˙ pathway in heart failure and its relationship with increased oxidative stress.