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Query: UMLS:C0018801 (heart failure)
 72,216 document(s) hit in 31,850,051 MEDLINE articles (0.00 seconds)

Patients with end-stage renal disease (ESRD) are at high risk for cardiovascular disease (CVD) and therefore should be treated according to ACC/AHA Guidelines. Scant data are available concerning the actual use of cardioprotective drugs in this population. The use of angiotensin-converting enzyme inhibitors (ACE-I), beta-blockers, aspirin, and statins was assessed in 271 (72% males, 66% Caucasians) high-risk ESRD patients on hemodialysis. The study population comprised 27% smokers, 95% with hypertension, 38% with diabetes, and 44% with dyslipidemia; 44% of patients had overt CVD at baseline, including 9% with heart failure, 9% with prior myocardial infarction, and 3% with previous myocardial revascularization. One-third of all patients were not receiving any cardioprotective drugs; among those patients who were, 42% were on one drug, 21% were on two, 3.7% were on three, and 1.5% were on four. The most prescribed agent was ACE-I (35.8%), followed by aspirin (30.6%), and beta-blockers (28.0%). The use of statins was remarkably and significantly low (4.1%) (p < 0.001), even in the higher risk subgroups (patients with diabetes or macrovascular disease). ACE-I plus aspirin was the most prescribed combination (8.5%). Cardioprotective agents recommended for risk-factor modification by the ACC/AHA Guidelines for their well-established efficacy in the general population were underutilized in this cohort of high-risk hypertensive hemodialysis patients, despite an elevated prevalence of clinically evident CVD. Speculatively, this fact may be relevant to better understand the known increased cardiovascular morbidity-mortality associated with chronic renal disease.
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PMID:Underuse of American College of Cardiology/American Heart Association Guidelines in hemodialysis patients. 1765 18

A best evidence topic in cardiac surgery was written according to a structured protocol. The question addressed was whether the optimal treatment strategy for acute prosthetic valve thrombosis (PVT) is surgical management or thrombolytic therapy. Using the reported search 96 papers were identified. Twelve papers represented the best evidence on the subject, and the author, journal, date and country of publication, patient group studied, study type, relevant outcomes, results and study comments and weaknesses were tabulated for these. Recent AHA/ACC guidelines were also included, as were two large case series of surgical management for comparison. We conclude that the management of obstructive PVT remains widely debated due to a lack of randomised controlled trials. Surgery has been the traditional management of choice, but thrombolysis has recently been proposed as a first-line therapy. Both surgery and thrombolysis can be used with high rates of success and relatively low complication rates, though NYHA class at presentation has a significant bearing on surgical mortality and thrombus size affects complication rates with thrombolysis. Thrombolysis appears particularly favoured when the thrombus area as assessed by transoesophageal echocardiography is small (<0.8 cm(2)), as high success rates and low complication rates have been reported, and thrombolysis does not preclude the patient from proceeding to surgery if it fails. Presentation in a high NYHA class of heart failure or cardiogenic shock is the most difficult patient to decide between surgery and thrombolysis. Surgery for these patients may remain the mainstay of treatment unless the clot burden is particularly small or the patient's co-morbidities make surgery unacceptably high-risk.
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PMID:Is thrombolysis or surgery the best option for acute prosthetic valve thrombosis? 1803 1

Neurohormonal activation and increased sympathetic stimulation are among the factors that have been linked to the development and progression of left ventricular dysfunction (LVD) and heart failure (HF) in post-myocardial infarction (MI) patients. Various available pharmacologic therapies can target these factors and improve many aspects of the disease, depending on the degree of LVD. The American College of Cardiology/American Heart Association (ACC/AHA) guidelines recommend angiotensin-converting enzyme inhibitors, angiotensin receptor blockers, beta-blockers, and aldosterone antagonists because of their proven favorable effects on symptoms, left ventricular function, cardiac remodeling, hospitalization rates, and survival. However, they are not being used in over two thirds of patients with post-MI LVD. This review illustrates the impact of these therapies on post-MI LVD patients using evidence from multiple clinical trials. In addition, current and emerging treatments for acute decompensated HF will be outlined.
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PMID:Pharmacologic therapies across the continuum of left ventricular dysfunction. 1872 88

BACKGROUND: Abnormal glucose metabolism and insulin resistance have been associated with heart failure incidence, severity, and mortality. Metabolic parameters such as hepatic glucose production may be altered by beta-adrenoceptor antagonists in patients with heart failure. OBJECTIVE: This study evaluated the effects of metoprolol or carvedilol up-titration on fasting glucose, insulin resistance and beta(2)-mediated glucose production in patients with chronic heart failure. METHODS: This was a prospective, randomized, active comparator study in 15 patients with AHA/ACC Stage C systolic dysfunction HF stable on medical therapy. Participants were randomized to metoprolol 25mg daily or carvedilol 3.125mg twice daily. Metoprolol was titrated to a target of 200mg daily, and carvedilol was titrated to 25mg twice daily over 8weeks. Insulin resistance as assessed by the homeostatic model, and terbutaline-induced glucose production (AUC(0-180)), were assessed at baseline and at 4 subsequent beta-blocker titration visits over 8 weeks. RESULTS: In all 15 patients, terbutaline-induced glucose AUC(0-180) decreased (p=0.0006) as beta-blocker doses increased. A significant reduction in glucose AUC(0-180) compared to baseline was only noted in patients taking metoprolol at 100mg daily (-2424.6 [95% CI -372.6 to -4478.4] mg/dL*min) and 200mg daily (-2437.2 [95% CI -15.1 to -4604.4] mg/dL*min), and not observed in those taking carvedilol. After beta-blocker titration, fasting glucose concentrations for the metoprolol and carvedilol groups were 86.9 (95% CI 89.8-101.6) mg/dL and 95.7 (95% CI 89.8-101.6) mg/dL, respectively (p=0.0273), adjusted for baseline values. There was no significant difference between metoprolol and carvedilol on insulin resistance. CONCLUSION: Increasing doses of beta-blockers are associated with decreased in beta2-mediated glucose production in heart failure. Metoprolol, but not carvedilol, decreases hepatic glucose production at commonly used heart failure doses.
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PMID:Effects of Beta-Blocker Titration on Glucose Homeostasis in Heart Failure. 1967 80

Cardiac resynchronization therapy (CRT) is an important device-based, non-pharmacological approach that has shown, in large randomized trials, to improve left ventricular (LV) function and reduce both morbidity and mortality rates in selected patients affected by advanced heart failure (HF): New York Heart Association (NYHA) functional class III-IV, reduced LV systolic function with an ejection fraction (EF) <or=35%, QRS duration >or=120 ms, on optimal medical therapy, and who were in sinus rhythm. For the first time, the latest ESC and AHA/ACC/HRS Guidelines have considered atrial fibrillation (AF) patients, who constitute an important subgroup of HF patients, as eligible to receive CRT. Nevertheless, these Guidelines did not include a strategy for defining differentiated approaches according to AF duration or burden. In this review, the authors explain in which way AF may interfere with adequate CRT delivery, how to manage different AF burden, and finally present a brief overview on the effects of CRT in AF patients.
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PMID:Cardiac resynchronization therapy in heart failure patients with atrial fibrillation. 1986 96

Atrial fibrillation (AF) is the most common sustained arrhythmia, affecting more than 2.2 million Americans. ACC/AHA/ESC guidelines for the management of patients with AF recommend amiodarone for maintaining sinus rhythm. Dronedarone is a derivative of amiodarone indicated for the treatment of AF. To provide an overview of dronedarone with a focus on the phase III trials and discuss unresolved questions of dronedarone. A literature search was conducted via the PubMed database using the keyword "dronedarone." Search was limited to human trials in english. The FDA website was searched for briefing documents and subcommittee meetings on dronedarone. Clinicaltrials.gov was searched with the keyword dronedarone for upcoming or unpublished clinical trials. Five phase III trials are available for dronedarone: ANDROMEDA, EURIDIS/ADONIS, ATHENA, ERATO, and DIONYSIS. EURIDIS/ADONIS and ATHENA demonstrated a reduction AF recurrence with dronedarone compared to placebo. The ANDROMEDA trial recruited patients with recent hospitalization for heart failure and was terminated due to an excess of deaths in the dronedarone group. The DIONYSIS trial was a comparative effectiveness trial that demonstrated less efficacy for dronedarone but improved tolerability compared to amiodarone. Dronedarone represents an option in the management of AF in select patients. Dronedarone is not appropriate in patients with recently decompensated heart failure or those treated with strong CYP3A4 inhibitors or medications prolonging the QT interval. Dronedarone appears to have improved tolerability at the expense of decreased efficacy when compared to amiodarone. Questions remain on the long-term safety, use in patients with heart failure, retreatment after dronedarone or amiodarone failure, and comparative efficacy with a rate control strategy.
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PMID:Dronedarone: current evidence and future questions. 2007 58

A renal artery stenosis (RAS) is common among patients with atherosclerosis, up to a third of patients undergoing cardiac catheterization. Fibromuscular dysplasia is the next cause of RAS, commonly found in young women. Atherosclerosis RAS generally progresses overtime and is often associated with loss of renal mass and worsening renal function (RF). Percutaneous renal artery stent placement is the preferred method of revascularization for hemodynamically significant RAS according to ACC and AHA guidelines. Several randomized trials have shown the superiority of endovascular procedures to medical therapy alone. However, two studies ASTRAL and STAR studies were recently published and did not find any difference between renal stenting and medical therapy. But these studies have a lot of limitations and flaws as we will discuss (poor indications, poor results, numerous complications, failures, poor technique, inexperienced operators, ecc.). Despite these questionable studies, renal stenting keeps indications in patients with: uncontrolled hypertension; ischemic nephropathy; cardiac disturbance syndrome (e.g. "flash" pulmonary edema, uncontrolled heart failure or uncontrolled angina pectoris); solitary kidney. To improve the clinical response rates, a better selection of the patients and lesions is mandatory with: good non-invasive or invasive imaging; physiologic lesion assessment using transluminal pressure gradients; measurements of biomarkers (e.g., BNP); fractional flow reserve study. A problem remains after renal angioplasty stenting, the deterioration of the RF in 20-30% of the patients. Atheroembolism seems to play an important role and is probably the main cause of this R.F deterioration. The use of protection devices alone or in combination with IIb IIa inhibitors has been proposed and seems promising as shown in different recent reports. Renal angioplasty and stenting is still indicated but we need: a better patient and lesion selection; improvements in techniques and maybe the use of protection devices to reduce the risk of RF deterioration after renal stenting.
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PMID:Renal angioplasty and stenting: is it still indicated after ASTRAL and STAR studies? 2092 31

The nearly one-million estimated adult congenital heart disease (ACHD) patients in the United States now outnumber children with congenital heart disease (CHD). With continued improvement in survival due to surgical and medical management of patients born with CHD, there is an overall shift in the burden of care from childhood to adulthood. Due to this transitioning population, the probability of heart failure continues to increase with age and represents nearly one-quarter of all mortality in ACHD. Despite these sobering figures adult cardiologist and fellows continue to have limited exposure in the care of patients with congenital heart disease. The syndrome of heart failure represents a complex derangement of neurohormones, natriuretic peptides, and cytokines leading to progressive symptoms of exercise intolerance, dyspnea, and fatigue. Congenital heart patients represent a unique challenge in both categorization and protocol management of heart failure (HF). It remains unclear if the current four-stage ACC/AHA guidelines for diagnosis and treatment of HF in adults can serve as a meaningful framework for congenital heart patients. Additionally, widely used conventional HF therapy of beta-blockers and angiotensin converting enzyme inhibitors (ACE-I) have not demonstrated clear survival benefit in this population. Unfortunately, adequately powered and controlled randomized studies are grossly lacking and remain challenging to conduct. Nonetheless, a review of heart failure associated with ACHD is provided.
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PMID:A review of heart failure in adults with congenital heart disease. 2168 44

Chronic cardiac insufficiency manifests itself in a number of clinical syndromes with signs and symptoms characterized by low specificity and sensitivity. ESC and ACC/AHA experts propose to use brain natriuretic peptide (BNP) and/or N-terminal BNP propeptide (NT-proBNP) levels in combination with tissue velocity imaging (TVI) to facilitate diagnostics of this condition. BNP and NT-proBNP levels are highly specific and sensitive indicators of left ventricular myocardium overload while TVI reveals chronic cardiac insufficiency in the asymptomatic phase of its development. Q-analysis of TVI provides data on global and local myocardial contraction and relaxation and allows objective quantitative evaluation of these functions in lieu of less accurate subjective characteristic. A number of cohort studies have confirmed high specificity and sensitivity of TVI, BNP and NT-proBNP levels at the early stages of chronic cardiac insufficiency.
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PMID:[Modern principles of diagnostics of chronic cardiac insufficiency]. 2193 53

The prevalence of obesity continues to increase and represents one of the principal causes of cardiovascular morbidity and mortality. After the discovery of a specific receptor of the psychoactive principle of marijuana, the cannabinoid receptors and their endogenous ligands, several studies have demonstrated the role of this system in the control of food intake and energy balance and its overactivity in obesity. Recent studies with the CB1 receptor antagonist rimonabant have demonstrated favorable effects such as a reduction in body weight and waist circumference and an improvement in metabolic factors (cholesterol, triglycerides, glycemia etc). Therefore, the antagonism of the endocannabinoid (EC) system, if recent data can be confirmed, could be a new treatment target for high risk overweight or obese patients. Obesity is a growing problem that has epidemic proportions worldwide and is associated with an increased risk of premature death (1-3). Individuals with a central deposition of fats have elevated cardiovascular morbidity and mortality (including stroke, heart failure and myocardial infarction) and, because of a growing prevalence not only in adults but also in adolescents, it was reclassified in AHA guidelines as a "major modifiable risk factor" for coronary heart disease (4, 5). Although first choice therapy in obesity is based on correcting lifestyle (diet and physical activity) in patients with abdominal obesity and high cardiovascular risk and diabetes, often it is necessary to use drugs which reduce the risks. The EC system represents a new target for weight control and the improvement of lipid and glycemic metabolism (6, 7).
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PMID:Endocannabinoids and cardiovascular prevention: real progress? 2197 72


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