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Query: UMLS:C0018799 (heart disease)
 34,133 document(s) hit in 31,850,051 MEDLINE articles (0.00 seconds)

Secondary and infiltrative cardiomyopathies are the least common forms of cardiomyopathy and often are the most difficult to treat. In all cases, efforts should be made to establish a specific diagnosis because the removal or avoidance of the causative agent (eg, alcohol, cocaine, persistent tachycardia) holds the best promise for reversal of ventricular dysfunction. Patients who present with a dilated cardiomyopathy (DCM) should be treated with standard heart failure therapy. However, the "standard" is changing and clinicians need to take heed of results of recent trials establishing the role of beta-blockers, aldosterone, and angiotensin receptor antagonists in addition to the regimen of digoxin, diuretics and angiotensin-converting enzyme (ACE) inhibitors. In contrast, patients who present with a more infiltrative clinical picture often manifest more diastolic dysfunction and need strict volume control to maintain euvolemia. For patients with biopsy-proven myocarditis, immunosuppressive therapy generally should be considered in an effort to maintain and potentially improve ventricular function. Patients with sarcoid heart disease have shown the greatest response to high-dose corticosteroids. Patients with hemochromatosis related cardiomyopathy should be treated with iron chelation therapy and phlebotomy. The role of cardiac transplantation is limited, as most of the secondary and infiltrative causes of cardiomyopathy are associated with an adverse posttransplant outcome. Other surgical options, such as left ventricular assist devices, may offer hope to patients who would otherwise be ineligible for cardiac transplantation. On the horizon, biventricular pacing and treatments targeted at cytokines and hormonal receptors hold the promise of improving symptoms and prolonging survival by counteracting the deleterious effects of these secondary mediators.
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PMID:Secondary and Infiltrative Cardiomyopathies. 1109 42

Proven cardiovascular benefit from angiotensin-converting enzyme (ACE) inhibition is a cornerstone of evidence-based medicine. The first study to show dramatic benefits from ACE inhibition was the Cooperative North Scandinavian Enalapril Survival Study (CONSENSUS-I), in which a 31% decrease in the rate of death was observed in patients with severe heart failure at the end of 1 year of enalapril treatment (p = 0.001). This result led to large long-term studies-including Survival and Ventricular Enlargement (SAVE), Acute Infarction Ramipril Efficacy (AIRE), Trandolapril Cardiac Evaluation (TRACE), and Study of Left Ventricular Dysfunction (SOLVD)-which verified that ACE inhibition decreases heart failure, myocardial infarction (MI), and mortality, and that striking benefit could be observed within 30 days. Short-term studies of patients in the acute phase of a heart attack verified that ACE inhibition provided rapid benefits. A meta-analysis of short-term (up to 8 weeks) studies of ACE inhibition (including CONSENSUS-II, Gruppo Italiano per lo Studio della Sopravvivenza nell'Infarto Miocardico [GISSI]-3, International Study of Infarct Survival [ISIS]-4, and the Chinese Captopril Study [CCS]-1) demonstrated that post-MI risk was reduced by 10% within the first day of treatment. The immediacy of the benefit suggested that ACE inhibition not only improved cardiovascular function in failing hearts but also affected important mechanisms in patients without overt heart failure. Effects on more general mechanisms of heart disease suggested that patients with problems other than hypertension or heart failure might benefit from ACE inhibitors. The Heart Outcomes Prevention Evaluation (HOPE) study investigated the hypothesis that ACE inhibition would confer benefits to patients who were at high risk for cardiovascular events, but who were without left ventricular dysfunction or heart failure. Long-term reductions in MI, stroke, cardiac arrest, and heart failure, as well as improvements in mortality, were observed in this population after treatment with ACE inhibitors. Substudies of the HOPE study revealed that ACE inhibition reduced progression of atherosclerosis and improved myocardial remodeling. Taken together, these studies provide evidence that supports treatment of a broad population of patients at risk for cardiovascular events with ACE inhibitors. The next step is to combine ACE inhibition with other treatments to maximize patient benefit. The Ongoing Telmisartan Alone and in combination with Ramipril Global Endpoint Trial (ONTARGET) will compare the efficacy of an ACE inhibitor (ramipril) with an angiotensin receptor blocker (telmisartan), and determine whether these treatments in combination will further reduce morbidity and mortality from cardiovascular disease.
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PMID:Angiotensin II and trials of cardiovascular outcomes. 1183 5

Diastolic heart failure is defined clinically when signs and symptoms of heart failure are present in the presence of preserved left ventricular systolic function (ejection fraction >45%). The incidence and prevalence of primary diastolic heart failure increases with age and it may be as high as 50% in the elderly. Age, female gender, hypertension, coronary artery disease, diabetes, and increased body mass index are risk factors for diastolic heart failure. Hemodynamic consequences such as increased pulmonary venous pressure, post-capillary pulmonary hypertension, and secondary right heart failure as well as decreased cardiac output are similar to those of systolic left ventricular failure, although the nature of primary left ventricular dysfunction is different. Diagnosis of primary diastolic heart failure depends on the presence of preserved left ventricular ejection fraction. Assessment of diastolic dysfunction is preferable but not mandatory. It is to be noted that increased levels of B-type natriuretic peptide does not distinguish between diastolic and systolic heart failure. Echocardiographic studies are recommended to exclude hypertrophic cardiomyopathy, infiltrative heart disease, primary valvular heart disease, and constrictive pericarditis. Myocardial stress imaging is frequently required to exclude ischemic heart disease. The prognosis of diastolic heart failure is variable; it is related to age, severity of heart failure, and associated comorbid diseases such as coronary artery disease. The prognosis of severe diastolic heart failure is similar to that of systolic heart failure. However, cautious use of diuretics and/or nitrates may cause hypotension and low output state. Heart rate control is essential to improving ventricular filling. Pharmacologic agents such as angiotensin receptor blockers, angiotensin-converting enzyme inhibitors, and calcium channel blockers are used in selected patients to decrease left ventricular hypertrophy. To decrease myocardial fibrosis, aldosterone antagonists have a potential therapeutic role. However, prospective controlled studies will be required to establish their efficacy in primary diastolic heart failure.
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PMID:Primary diastolic heart failure. 1198 32

Diabetes has long been recognized as a risk factor for heart disease. Recent evidence has brought to light complex interactions that seem to influence both the renal and the vascular complications of diabetes. The use of angiotensin-converting enzyme inhibitors and angiotensin receptor blockers has been shown to ameliorate renal and cardiac risks in both type 1 and type 2 diabetes to a degree that is disproportionate to blood pressure-lowering effects. The judicious use of these agents can materially improve the prognosis for patients with diabetes.
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PMID:Angiotensin blockade in type 2 diabetes: what the new evidence tells us about renal and cardiac complications. 1204 87

In managing atrial fibrillation (AF), the main therapeutic strategies include rate control, termination of the arrhythmia, and the prevention of recurrences and thromboembolic events. Safety and efficacy considerations are important in optimizing the choice of an antiarrhythmic drug for the treatment of AF. Recently approved antiarrhythmics, such as dofetilide, and promising investigational drugs, such as azimilide and dronedarone, may change the treatment landscape for AF. For medical conversion of recent-onset AF, class IC antiarrhythmic drugs, administered as an oral bolus, have been demonstrated to be the most efficacious pharmacologic conversion agents. Intravenous ibutilide and oral dofetilide both have efficacies superior to placebo in controlled trials for converting persistent AF. Comparative trials in paroxysmal AF have demonstrated that flecainide, propafenone, quinidine, and sotalol are equally effective in preventing recurrences of AF. Amiodarone has been demonstrated to be more efficacious than propafenone or sotalol in the Canadian Trial of Atrial Fibrillation. In persistent AF, twice-daily dofetilide has been shown to be as or more effective than low-dose sotalol given twice daily for the maintenance of sinus rhythm in patients with AF. Trials have demonstrated that subjective adverse effects are less frequent with class IC drugs, sotalol, and dofetilide compared with such drugs as quinidine. In patients without structural heart disease, flecainide, propafenone, and D,L-sotalol are the initial drugs of choice, given their reasonable efficacy, low incidence of subjective side effects, and lack of significant end-organ toxicity. Treating AF in patients with left ventricular dysfunction can be difficult because of associated electrophysiologic derangements, potential proarrhythmic concerns, and negative inotropic effects of antiarrhythmics. Some data exist suggesting that angiotensin-converting enzyme inhibitors and angiotensin receptor blockers can prevent AF either by preventing atrial dilation and stretch-induced arrhythmias or by blocking the renin-angiotensin system. In post-myocardial infarction patients, D,L-sotalol, dofetilide, and amiodarone-and in congestive heart failure patients, amiodarone and dofetilide-have demonstrated neutral effects on survival in controlled trials. In the Congestive Heart Failure Survival Trial of Antiarrhythmic Therapy (CHF-STAT), amiodarone lowered the frequency of AF development and improved left ventricular ejection fraction over time. In CHF-STAT, there was lower mortality in patients who converted from AF to sinus rhythm. Dofetilide decreased rehospitalization for congestive heart failure in the Danish Investigations of Arrhythmia and Mortality on Dofetilide (DIAMOND) trials. Neutral effects on survival and favorable hemodynamics have positioned amiodarone and dofetilide as the antiarrhythmics of choice in patients with left ventricular dysfunction. In post-myocardial infarction patients, sotalol is an additional agent to consider for treatment of AF in this setting.
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PMID:Old and new antiarrhythmic drugs for converting and maintaining sinus rhythm in atrial fibrillation: comparative efficacy and results of trials. 1267 Jun 38

Anemia is prevalent in renal transplant recipients (RTRs), as it is in all chronic kidney disease (CKD) populations. Mild anemia occurs in up to 40% of RTRs, and more severe anemia (110 g/L) occurs in about 9% to 22% of patients. As in CKD, impaired graft (renal) function is a major predictor of anemia identified in nearly all studies, suggesting a major role for erythropoietin deficiency. Chronic inflammation, malnutrition, iron deficiency, and medications (angiotensin converting enzyme inhibitors, angiotensin receptor blockers, mycophenolate, azathioprine, and sirolimus) are contributory factors seen in some, but not all, studies. Although pathophysiologic and observational data strongly support a causal association between low hemoglobin levels and cardiovascular outcomes in RTRs, no randomized controlled trial to date has been able to show a clear benefit of anemia treatment on cardiovascular outcomes or mortality in either RTR or other CKD populations. This important paradox has led some investigators to question the causal nature of the association between anemia and heart disease. Resolution of this paradox, at least for patients with stage 2/3 CKD, will depend on the outcome of randomized controlled trials currently in progress. Similar trials sorely are needed in renal transplant populations. In the interim, current opinion favors treating persistent anemia in RTRs to achieve targets similar to those recommended for dialysis and CKD patients.
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PMID:Anemia, renal transplantation, and the anemia paradox. 1694 69

Hypertension is one of the main risk factors of cardiovascular diseases. Hypertension in childhood is defined as blood pressure > or = 95. percentile for healthy children population. The prevalence of hypertension in childhood is considerably lower than in adults and is about 1%. The aetiology of hypertension in childhood differs from adult population--in children secondary forms are more common than primary, however, in adolescents primary form already prevails. In general, the younger the child and the higher the blood pressure, the more probably it is a secondary form of hypertension. The most common causes of secondary hypertension are renal diseases (renoparenchymal or renovascular). Cardiac diseases (aortic isthmus stenosis), endocrinopathies, central nervous system disorders or use of hypertensinogenic drugs are less frequent causes of secondary hypertension. Each child with hypertension has to be carefully examined; the extent of the examination depends on the age of the child and severity of hypertension. The main task for the investigation is to exclude or reveal secondary form of hypertension, which could be causally treated (e.g. angioplasty in renal artery stenosis). Treatment of hypertension is non-pharmacological and pharmacological (angiotensin-converting enzyme inhibitors, beta-blockers, calcium channel blockers, diuretics, angiotensin receptor blockers).
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PMID:[Arterial hypertension in children and adolescents]. 1699 18

In the United States, 18 million adults have diabetes and an additional 16 million have impaired glucose tolerance. Of these patients, 75% will die of some form of heart or vascular disease. Furthermore, recent data suggest that even prediabetic patients are at increased risk for cardiovascular (CV) events. Patients with diabetes often have multiple comorbid CV risk factors (e.g., dyslipidemia, hypertension, hyperglycemia) that synergistically interact to accelerate the pathogenesis of CV disease and dramatically increase the risk for CV events. For example, compared with patients without diabetes, patients with diabetes have a 3- to 5-fold increased risk of death due to congestive heart disease at every cholesterol level and are at increased risk for hypertension and hypertension-related CV events. Patients with diabetes are likely to benefit from intensive therapy incorporating multiple CV risk-reduction strategies. Lipid-modification--primarily reducing levels of low-density lipoprotein cholesterol (LDL-C) and triglycerides and increasing high-density lipoprotein cholesterol (HDL-C) through pharmacologic and lifestyle intervention--is an integral part of such therapy. Patients with diabetes will also benefit from intensive blood pressure-lowering therapy with multiple classes of antihypertensives including angiotensin-converting enzyme inhibitors and angiotensin receptor blockers in particular, as well as concomitant antiplatelet therapy. An intensive risk-reduction approach combining these treatments would dramatically reduce the incidence of CV morbidity and mortality in this high-risk patient population.
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PMID:The patient with diabetes: preventing cardiovascular complications. 1743 22

The renin-angiotensin system is primarily responsible for regulating vascular tone. Drugs that inhibit this pathway, angiotensin-converting enzyme inhibitors and angiotensin receptor antagonists, are widely used to treat hypertension and a variety of cardiomyopathies. Recent studies have shown that, in addition to reducing blood pressure, these drugs also modulate inflammation, adhesion molecule expression, and fibrosis. To assess the therapeutic potential of these inhibitory agents for the treatment of inflammatory heart disease, the drugs have been tested in experimental models of infectious and autoimmune myocarditis. This review summarizes the results of studies examining the efficacy of angiotensin converting enzyme inhibitors and angiotensin receptor antagonists for the treatment of mouse models of virus-induced and parasite-induced myocarditis, as well as autoimmune cardiomyopathy. The collective results strongly support the use of renin-angiotensin modulation for the treatment of myocarditis. Importantly, this therapeutic approach seems to downregulate autoimmunity without causing immune suppression which may enhance the survival of the disease-initiating infectious agent.
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PMID:Treatment of experimental myocarditis via modulation of the renin-angiotensin system. 1750 15

The prevalence of hypertension in blacks in the United States is among the highest in the world. Compared with whites, blacks develop hypertension at an earlier age, their average blood pressures are much higher and they experience worse disease severity. Consequently, blacks have a 1.3 times greater rate of nonfatal stroke, 1.8 times greater rate of fatal stroke, 1.5 times greater rate of heart disease death, 4.2 times greater rate of end-stage kidney disease, and a 50% higher frequency of heart failure; overall, mortality due to hypertension and its consequences is 4 to 5 times more likely in African Americans than in whites. The increased prevalence of hypertension and excessive target organ damage is due to a combination of genetic and, most likely, environmental factors. There are no clinical trial data at present to suggest that lower-than-usual BP targets should be set for high-risk demographic groups such as African Americans. The primary means of prevention and early treatment of hypertension in African Americans will be the appropriate use of lifestyle modification. The International Society of Hypertension in Blacks guidelines realize that most patients will require combination therapy, many of them first-line, to reach appropriate BP goals. Although certain classes and combinations of antihypertensive agents have been well-established to be effective, the choice of drugs for combination therapy in African American patients may be different. Within the African American group, the responsiveness to monotherapy with ACE inhibitors, angiotensin receptor blockers, and beta blockers may be less than the responsiveness to diuretics and calcium channel blockers, but these differences are corrected when diuretics are added to the neurohormonal antagonists. Of note, African American patients with systolic BP >15 mm Hg or a diastolic BP >10 mm Hg above goal should be treated with first-line combination therapy.
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PMID:The management of hypertension in African Americans. 1766 68


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