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Biomedical subjects

Gregg C Fonarow

Publications and source records attributed to Gregg C Fonarow.

At least 109 records · Page 6Linked to original sources
PubMed2003

Prevention of heart failure: effective strategies to combat the growing epidemic.

In light of the increasing prevalence, morbidity, and mortality of heart failure, effective preventative strategies are urgently needed. Risk factors for heart failure include coronary artery disease and other atherosclerotic vascular diseases, hypertension, diabetes, renal insufficiency, obesity, and family history of cardiomyopathy. Essential strategies for prevention of heart failure are modification of risk factors for heart failure development; comprehensive hypertension, atherosclerosis, and diabetes treatment; and detection and treatment of asymptomatic left ventricular dysfunction. The B-type natriuretic peptide assay may aid in identifying asymptomatic left ventricular dysfunction in patients with risk factors for heart failure. In patients with hypertension, atherosclerosis, and/or diabetes, angiotensin-converting enzyme inhibitor, beta-blocker, aspirin, and statin therapy can prevent progression to symptomatic heart failure. Avoidance of calcium channel-blockers as first-line antihypertensive therapy can also reduce the risk of heart failure. There remain substantial opportunities to improve implementation of therapies proven to prevent heart failure in the large number of patients at risk.

Diabetic Angiopathies↗
PubMed2003

Combining natriuretic peptides and necrosis markers in determining prognosis in heart failure.

Despite significant advances in medical therapy, patients with heart failure remain at increased risk of overall mortality, progressive ventricular dysfunction, and sudden cardiac death. Although a number of individual clinical and laboratory variables have been identified as being associated with increased mortality risk in heart failure, there remains a clear need for an integrated, accurate method of determining prognosis. Elevated plasma B-type natriuretic peptide (BNP) has been demonstrated to be a powerful marker for prognosis and risk stratification in the setting of heart failure. Patients with elevated BNP levels have been shown to be at significantly higher risk for heart failure admission or death, and higher BNP levels are associated with progressively worse prognosis. Although cardiac troponins are a well-established diagnostic and prognostic marker in acute coronary syndromes, emerging data suggest that cardiac troponins also provide independent prognostic information in heart failure. Detection of cardiac troponins in the serum of patients with heart failure has been shown to be associated with an impaired hemodynamic profile, progressive decline in left ventricular systolic function, and shortened survival. Combining a marker of myocyte injury-cardiac troponin-with BNP in a multimarker strategy appears to be a useful tool for improving risk assessment and triage in patients with heart failure. Heart failure patients with detectable cardiac troponin I and high BNP levels have been shown to have a 12-fold increased mortality risk compared with those with both undetectable cardiac troponin I and lower BNP. Integrating this multimarker approach into the routine assessment of heart failure patients will allow clinicians to more accurately identify high-risk patients who may derive increased benefit from intensive management strategies.

Biomarkers↗
PubMed2003

The role of in-hospital initiation of cardiovascular protective therapies to improve treatment rates and clinical outcomes.

Patients with acute myocardial infarction (MI) face a high risk of recurrent cardiovascular events, repeat hospitalizations, heart failure, and mortality. There is compelling scientific evidence that antiplatelet therapy, beta-blockers, angiotensin-converting enzyme inhibitors, and lipid-lowering therapy reduce these risks in patients with acute MI. Despite this evidence and national guidelines, a number of studies in a variety of clinical settings have documented that a significant proportion of patients with acute MI is not being treated with these guideline-recommended, evidence-based therapies when receiving conventional care. The demonstration that initiation of cardiovascular protective medications, including lipid-lowering therapy, prior to hospital discharge for atherosclerotic cardiovascular events results in a marked increase in treatment rates, improved long-term patient compliance, and better clinical outcomes has led to the revision of national guidelines to endorse this approach as the standard of care. Physicians have been reluctant to initiate beta-blockers in post-MI patients with significant left ventricular dysfunction and/or heart failure symptoms, and this reluctance has contributed to the treatment gap. Recent studies suggest that when the beta-blocker carvedilol is initiated in acute-MI patients with left ventricular dysfunction with or without symptoms of heart failure prior to hospital discharge, it is safe and effective and improves clinical outcomes. Adopting in-hospital initiation of cardiovascular protective medications as the standard of care for patients hospitalized with acute MI could dramatically improve treatment rates and thus substantially reduce the risk of future cardiovascular events and hospitalizations and prolong life in the large number of patients hospitalized each year.

Adrenergic beta-Antagonists↗
PubMed2003

In-hospital initiation of cardiovascular protective medications for patients undergoing percutaneous coronary intervention: taking advantage of the teachable moment.

Following percutaneous coronary interventions (PCI), patients remain at risk for atherosclerotic vascular disease progression, cardiovascular events and mortality. There is compelling scientific evidence that antiplatelet therapy, beta-blockers, angiotensin-converting enzyme (ACE) inhibitors and lipid-lowering therapy reduce cardiovascular events, hospitalizations and mortality in patients after PCI. Despite this evidence and national guidelines, a number of studies in a variety of clinical settings have documented that a significant proportion of post-PCI patients are not receiving treatment with these guideline-recommended, evidence-based therapies when guided by conventional care. The demonstration that initiation of cardiovascular protective medications, including lipid-lowering therapy, prior to hospital discharge for cardiovascular events and/or procedures results in a marked increase in treatment rates, improved long-term patient compliance and better clinical outcomes has led to the revision of national guidelines to endorse this approach as the standard of care. Hospital-based cardiovascular performance improvement programs have demonstrated substantial improvements in treatment rates as well as the quality of PCI and other coronary heart disease patient care. Adopting in-hospital initiation of cardiovascular protective medications as the standard of care for patients undergoing PCI could dramatically improve treatment rates and thus substantially reduce the risk of future cardiovascular events, reduce hospitalizations and prolong life in the large number of patients undergoing PCI each year.

Angioplasty, Balloon, Coronary↗
PubMed2003

The Acute Decompensated Heart Failure National Registry (ADHERE): opportunities to improve care of patients hospitalized with acute decompensated heart failure.

Heart failure is a leading cause of hospitalization for adults in the United States. Patients hospitalized with acute decompensated heart failure (ADHF) face a substantial risk of in-hospital mortality and rehospitalization. Despite the large number of patients hospitalized and this substantial risk, data on these patients have been limited and there has been little effort to improve the quality of care for patients hospitalized with ADHF. The Acute Decompensated HEart Failure National REgistry (ADHERE(tm)) was designed to bridge this gap in knowledge and care by prospectively studying characteristics, management, and outcomes in a broad sample of patients hospitalized with ADHF. Participating community and university hospitals identified patients with a primary or secondary discharge diagnosis of heart failure and collected medical history, management, treatments, and health outcomes via secure web browser technology. As of July 2003, 65,180 patients have been enrolled from 263 hospitals. Initial data have provided important insights into the clinical characteristics, patterns of care, and outcomes of these patients. ADHERE documents significant delays in diagnosis and initiation of ADHF therapies as well as substantial under-use of evidence-based, guideline-recommended chronic heart failure therapies at hospital discharge. As such, there are substantial opportunities to improve the quality of care for ADHF patients in the nation's hospitals. The ADHERE Hospital Toolkit has been designed to provide hospital teams with effective proactive instruments to improve the quality of care for patients with ADHF. If successfully implemented, the improvements in short- and long-term clinical outcomes for ADHF patients are expected to be substantial.

Heart Failure↗
PubMed2003

The management of the diabetic patient with prior cardiovascular events.

Patients with diabetes are at high risk for cardiovascular (CV) events and heart failure. Approximately 2-3 million diabetics in the U.S. have had a history of prior CV events. The prevalence of diabetes in patients with heart failure ranges from 24% reported in clinical trials to 47% among hospitalized patients, and an estimated 1-2 million persons in the U.S. have diabetes and heart failure. Diabetes substantially increases the risk of mortality after acute coronary syndromes and also increases the risk of hospitalizations and mortality in patients with heart failure. It is now recognized that activation of multiple neurohormonal systems is central in the pathophysiology of diabetes, CV events, and heart failure. Pharmacologic intervention in these systems (eg, angiotensin-converting enzyme (ACE) inhibition, aldosterone-receptor antagonism, and beta-blockade) has been shown to decrease morbidity and mortality in diabetics with prior CV events and/or heart failure. Despite this awareness, ACE inhibitors, aldosterone antagonists, and beta-blockers are underutilized, and deaths and hospitalizations caused by CV events and heart failure in diabetic patients have steadily increased. Concerns about an increased incidence of hypoglycemia, worsening dyslipidemia, and decreased insulin sensitivity resulting from the use of beta-blockers may be preventing physicians from prescribing these agents for diabetic patients. Beta-blockade in conjunction with ACE inhibition should be standard therapy for all diabetic patients. Optimal glycemic control therapy for patients with heart failure has not been well-defined, and there is an urgent need for randomized clinical trials to determine optimal treatment.

Adrenergic Agents↗
PubMed2002

Anemia is associated with worse symptoms, greater impairment in functional capacity and a significant increase in mortality in patients with advanced heart failure.

OBJECTIVES: This study aimed to evaluate the relationship between anemia and heart failure (HF) prognosis. BACKGROUND: Although it is known that chronic diseases, including HF, may be associated with anemia, the impact of hemoglobin (Hb) level on symptoms and survival in HF has not been fully defined. We analyzed a cohort of 1,061 patients with advanced HF (New York Heart Association [NYHA] functional class III or IV and left ventricular ejection fraction [LVEF] <40%) referred to a single center for evaluation and management. The Hb level was drawn at time of initial evaluation. Patients were divided into quartiles of Hb: Hb <12.3; Hb 12.3 to 13.6; Hb 13.7 to 14.8; Hb >14.8 g/dl. RESULTS: Mean Hb was 13.6, and values ranged from 7.1 to 19.0 g/dl. The Hb groups were similar in age, medication profile, LVEF, hypertension, diabetes, smoking status and serum sodium. Lower Hb was associated with an impaired hemodynamic profile, higher blood urea nitrogen and creatinine, and lower albumin, total cholesterol and body mass index. Patients in the lower Hb quartiles were more likely to be NYHA functional class IV (p < 0.0001) and have lower peak oxygen consumption (PKVO(2)) (p < 0.0001). Survival at one year was higher with increased Hb quartile (55.6%, 63.9%, 71.4% and 74.4% for quartiles 1, 2, 3 and 4, respectively). On multivariate analysis adjusting for known HF prognostic factors, low Hb proved to be an independent predictor of mortality (relative risk 1.131, confidence interval 1.045 to 1.224 for each decrease of 1 g/dl). CONCLUSIONS: In chronic HF, relatively mild degrees of anemia are associated with worsened symptoms, functional status and survival.

Adolescent↗
PubMed2002

Statin therapy after acute myocardial infarction: are we adequately treating high-risk patients?

After acute myocardial infarction, patients remain at high risk for recurrent cardiovascular events and mortality. Despite the compelling scientific and clinical trial evidence that lipid-lowering medications reduce mortality in patients after acute myocardial infarction, this life-saving therapy continues to be underutilized. A number of studies in a variety of clinical settings have documented that a significant proportion of patients after myocardial infarction are not receiving treatment with lipid-lowering medications when guided by conventional care. It has recently been demonstrated that implementation of a hospital-based system for initiation of statins prior to hospital discharge results in a marked increase in treatment rates, improved long-term patient compliance, more patients reaching low-density lipoprotein levels of less than 100 mg/dL, and improved clinical outcomes. Adopting in-hospital initiation of lipid-lowering medications as the standard of care for patients hospitalized with acute myocardial infarction could dramatically improve treatment rates and thus substantially reduce the risk of future coronary events and prolong life in the large number of patients hospitalized each year.

Cardiovascular Diseases↗
PubMed2002

Prevention of heart failure.

In light of the increasing prevalence, morbidity, and mortality of heart failure, preventative strategies are urgently needed. Risk factors include coronary artery disease, renal insufficiency, diabetes, and smoking. Essential strategies for prevention of heart failure are modification of risk factors for its development, and detection and treatment of asymptomatic left ventricular dysfunction (ALVD). In patients with ALVD, angiotensin-converting enzyme (ACE) inhibitor and beta-blocker therapy can prevent progression to symptomatic heart failure. Additional recently identified preventative strategies include ACE inhibitor therapy for all coronary artery disease and diabetic patients, clopidogrel therapy in acute coronary syndromes, and avoidance of calcium channel blockers and alpha-blockers as first-line antihypertensive therapy.

Adrenergic beta-Antagonists↗
PubMed2002

Giant cell myocarditis in a young man responsive to T-lymphocyte cytolytic therapy.

We describe a case of a 40-year-old man who presented with recent-onset, rapidly decompensating heart failure, and who was found to have giant cell myocarditis (GCM) on biopsy. The patient responded to myocardial rest on a biventricular assist device, as well as immunosuppression that included eradication of T cells using OKT3 therapy, coupled with high-dose steroids. The patient was successfully weaned off mechanical support, and ultimately discharged home, where he continues to do well. Based on a review of the clinical and experimental literature, we believe treatment with T-lymphocytic cytolytic therapy may be beneficial. Further studies using this therapy in the treatment of GCM are warranted.

Adult↗
PubMed2002

Recent trends in early outcome of adult patients after heart transplantation: a single-institution review of 251 transplants using standard donor organs.

Older age, prior transplantation, pulmonary hypertension, and mechanical support are commonly seen in current potential cardiac transplant recipients. Transplants in 436 consecutive adult patients from 1994 to 1999 were reviewed. There were 251 using standard donors in 243 patients (age range 18-69 years). To emphasize recipient risk, 185 patients who received a nonstandard donor were excluded from analysis. The indications for transplant were ischemic heart disease (n = 123, 47%), dilated cardiomyopathy (n = 82, 32%), and others (n=56, 21%). One hundred and forty-nine (57%) recipients were listed as status I; 5 and 6% were supported with an intra-aortic balloon and an assist device, respectively. The 30-d survival and survival to discharge were 94.7 and 92.7%, respectively; 1-year survival was 89.1%. Causes of early death were graft failure (n = 6), infection (n = 4), stroke (n = 4), multiorgan failure (n = 3) and rejection (n = 2). Predictors were balloon pump use alone (OR= 11.4, p =0.002), pulmonary vascular resistance > 4 Wood units (OR = 5.7, p = 0.007), pretransplant creatinine > 2.0 mg/dL (OR = 6.9, p = 0.004) and female donor (OR = 8.3, p = 0.002). Recipient age and previous surgery did not affect short-term survival. Heart transplantation in the current era consistently offers excellent early and 1-year survival for well-selected recipients receiving standard donors. Early mortality tends to reflect graft failure while hospital mortality may be more indicative of recipient selection.

Adolescent↗
PubMed2002

Low serum total cholesterol is associated with marked increase in mortality in advanced heart failure.

BACKGROUND: Although hypercholesterolemia is a well-defined risk factor for morbidity and mortality in coronary artery disease, the relationship between cholesterol and heart failure (HF) has rarely been investigated. METHODS: Cholesterol and lipoproteins were measured in 1,134 patients with advanced HF who presented to a single center for HF management and transplant evaluation. Patients were stratified into five groups based on quintiles of total cholesterol (TC) level, and differences in patient characteristics and survival were evaluated. RESULTS: Patients with low TC had significantly lower low-density lipoprotein (LDL) cholesterol, high-density lipoprotein (HDL) cholesterol, triglycerides (TG), sodium, albumin, left ventricular ejection fraction, and cardiac output. The TC quintiles were similar in terms of HF etiology, hypertension, diabetes, and lipid-lowering therapy at time of referral. TC, LDL, HDL, and TG each predicted survival (P < or = .01) on univariate analysis, with improved survival at higher levels. After adjustment for risk factors using a Cox proportional hazards model, relative risks were 2.071, 1.369, 1.391, 1.006 for the first, second, third, and fourth TC quintiles, with quintile 5 as reference. CONCLUSIONS: Serum TC represents a novel prognostic factor for patients with advanced HF. Further studies are necessary to investigate a potential role of low cholesterol and lipoproteins in the pathophysiology of HF progression.

Adolescent↗
PubMed2002

Emotional well-being of heart failure patients and their caregivers.

BACKGROUND: Heart failure (HF) dramatically affects the lives of both patients and their caregivers, yet limited research exists examining the relationship between emotional well-being of HF patients and their caregivers. Therefore, we conducted a study to (1) describe and compare the emotional well-being of HF patients and their caregivers, (2) determine if gender differences exist in emotional well-being of patients and caregivers, and (3) identify factors associated with emotional well-being of HF patients. METHODS: The emotional well-being of 103 patient-caregiver dyads was assessed using the mental health subscale of the SF-12. RESULTS: Patients were 57.6 +/- 12.1 years, predominantly Caucasian (76.7%) and male (67.0%). Caregivers were 59.5 +/- 17.6 years, predominantly females (70.9%) and spouses of patients with HF (82.6%). Patients had significantly lower (poorer) emotional well-being scores than caregivers. Both gender and age were associated with patients' emotional well-being; male and younger participants had higher (better) scores than female and older patients (P <.05). In a multivariate model, patient's age, gender, and caregivers' emotional well-being accounted for 54% of the variance in patients' emotional well-being. CONCLUSION: We found that the emotional well-being of caregivers is associated with the emotional well-being of HF patients. Our findings suggest the need to focus on supporting caregivers and providing them with the strategies they need to support their loved ones with HF.

Adolescent↗
PubMed2002

Acupuncture inhibits sympathetic activation during mental stress in advanced heart failure patients.

BACKGROUND: In heart failure (HF) patients, muscle sympathetic nerve activity is increased, and HF patients with the greatest sympathetic activation have the poorest prognosis. In animals, acupuncture is sympathoinhibitory, and the most profound sympathoinhibition occurs in animals with the highest resting sympathetic nerve activity. The purpose of this study was to test the hypothesis that acupuncture is sympathoinhibitory in humans with HF. METHODS AND RESULTS: Fifteen advanced HF patients underwent acute mental stress testing before and during (1) "real" acupuncture (n = 10), (2) non-acupoint acupuncture (n = 10), and (3) no-needle acupuncture control (n = 10). Muscle sympathetic nerve activity (MSNA) was recorded using peroneal microneurography. Resting MSNA was not different before and after acupuncture (52 +/- 22 versus 50 +/- 21 bursts/min, P = NS). During mental stress, SNA increased significantly. This increase was eliminated following real acupuncture (mean delta MSNA pre-acupuncture versus post-acupuncture: 149 +/- 171 versus -169 +/- 130, P =.03), but not after non-acupoint or no-needle acupuncture controls. The changes in blood pressure and heart rate during mental stress were not attenuated by real or control acupuncture. CONCLUSION: Acute acupuncture attenuates sympathoexcitation during mental stress in advanced HF patients.

Acupuncture Therapy↗
PubMed2002

Treating to goal: new strategies for initiating and optimizing lipid-lowering therapy in patients with atherosclerosis.

Abstract: The National Cholesterol Education Program (NCEP) guidelines prepared by the Adult Treatment Panel (ATP) provide clinicians with recommendations for the clinical management of abnormal blood cholesterol to reduce the risk of cardiovascular events. The recently updated NCEP guidelines have included a number of key amendments such as the recognition of low high-density lipoprotein cholesterol (HDL-C) as a risk factor for cardiovascular disease, while maintaining the focus of treatment on lowering low-density lipoprotein cholesterol (LDL-C) levels. Several agents can be used to modify the lipid profile in-line with the NCEP ATP-III recommendations, but hydroxymethyl glutaryl coenzyme A (HMG-CoA) reductase inhibitors (statins) remain the most effective and best-tolerated drugs for lowering LDL-C. The optimal time to initiate drug therapy had been in question, although recent studies suggest in-hospital initiation following admission with cardiovascular disease reduces the risk of recurrent events and improves long-term patient compliance. Inpatient physicians and nurses therefore play a pivotal role in influencing not only short-term management needs, but also the long-term recovery of their patients. This role should not be underestimated, as recent surveys have highlighted a significant problem of undertreatment in patients with documented atherosclerosis with regards to lipid-lowering and other cardioprotective therapy. Although reversing patient undertreatment will require clinicians to address a variety of issues, systematic in-hospital initiation of currently available lipid-lowering therapies in patients with atherosclerotic vascular disease is likely to have major benefits, reducing the occurrence of cardiovascular events and saving lives. Several statins, cholesterol absorption inhibitors, novel metabolic inhibitors, and combinations of agents are currently in clinical development and it is hoped that these will also assist clinicians in the important task of getting patients to recommended LDL-C and HDL-C levels.

Cholesterol, LDL↗
PubMed2002

Beta-blocker therapy for heart failure: the standard of care.

Sympathetic nervous system activation plays an important role in the genesis of symptoms, functional impairment, progressive ventricular dysfunction, and mortality in patients with heart failure. Prospective, randomized clinical trials of beta-blockers in patients with heart failure have demonstrated mortality reductions in patients across the spectrum of clinical presentations and etiologies. Additionally, these trials have provided important information regarding the indications, dosing, and extent of therapeutic benefits of the different beta-blockers studied in patients with heart failure. The recognition that beta-blockers relieve symptoms, reduce hospitalizations, and prolong survival in patients with heart failure represents one of the most important therapeutic advances in the treatment of this complex disorder. Beta-blockers, along with angiotensin-converting enzyme inhibitors and aldosterone antagonists, now represent the standard of care for patients with heart failure.

Adrenergic beta-Antagonists↗