Biomedical subjects
J F Setaro
Publications and source records attributed to J F Setaro.
Long-term outcome in patients with congestive heart failure and intact systolic left ventricular performance.
Congestive heart failure (CHF) is typically associated with impaired left ventricular (LV) systolic performance. Few reports exist describing the long-term outcome in patients with CHF and normal LV systolic function. Fifty-two patients initially hospitalized with CHF and intact LV function (ejection fraction greater than or equal to 45%) were followed for 7 years. Mean age when initially identified was 71 +/- 11 years (range 36 to 96), and average LV ejection fraction was 61 +/- 11%. CHF was graded by a clinicoradiographic index, with a mean of 7.0 +/- 2.3 (range 3 to 12, 13 indicates worst CHF). A third heart sound was present in 19 patients (37%), and 17 (33%) had presented with acute pulmonary edema. Principal cardiovascular diagnoses were coronary artery disease in 27 (52%), hypertensive heart disease in 16 (31%) and restrictive cardiomyopathy in 7 (13%). At 7 years, cardiovascular mortality was 46% (24 of 52), and noncardiovascular mortality was 10% (5 of 52). Survival was not correlated with age, principal diagnosis, third heart sound, pulmonary edema at presentation, LV ejection fraction, or presence or degree of LV diastolic dysfunction. Cardiovascular morbidity, consisting of nonfatal recurrent CHF, myocardial infarction, unstable angina or other cardiovascular events occurred in 29% (15 of 52). Combined cardiovascular mortality and morbidity was 75% (39 of 52). In patients with CHF, intact LV systolic function does not confer the same favorable prognosis it defines in other clinical situations. For such patients, the risk of future cardiovascular events is high, a finding that should be considered when designing therapeutic strategies in this group.
The right ventricle in disorders causing pulmonary venous hypertension.
The right ventricle is frequently affected by pulmonary arterial hypertension of postcapillary obstructive origin. The disorders that cause states of pulmonary venous hypertension arise in the left ventricle, left atrium, or pulmonary veins. Biochemical factors, the pericardium, interventricular septum, and pulmonary arterial system combine to communicate the effects of these disorders to the right ventricle. Although not ideally suited to pressure loading, the right ventricle undergoes a series of structural and hemodynamic adaptations that allow for chronic compensation until failure supervenes, with characteristic clinical findings. Exercise may serve to magnify the abnormalities of right ventricular function. Correction of left-sided heart lesions with improvement in pulmonary venous hypertension is associated with favorable effects on the right ventricle. In states of left-sided heart failure, the level of right ventricular function may provide important prognostic information.
Right ventricular infarction.
Right ventricular myocardial infarction, long unrecognized because of a lack of diagnostic methods and unsupported beliefs regarding the dispensability of the right ventricle, may now be diagnosed using well-accepted criteria. Right ventricular infarction is clearly associated with anterior left ventricular infarction as well as inferior infarction. It may occur in 30% to 40% of patients with inferior infarction, although a much smaller percentage experience hemodynamic instability on the basis of right ventricular infarction. Pathophysiologically, right ventricular systolic and diastolic dysfunction are exacerbated by pericardial restraint and concomitant left ventricular dysfunction, accounting for the characteristic findings of cardiogenic shock and marked preload dependence in many patients. Right ventricular infarction may be suspected on the grounds of clinical presentation, physical examination, and enzymatic findings, and is confirmed using well-defined electrocardiographic, radionuclide, echocardiographic, and hemodynamic criteria. Once diagnosed, right ventricular infarction requires specific hemodynamic and pharmacologic management, including the judicious use of volume expansion and inotropic support. Several forms of mechanical and surgical intervention are of therapeutic value in treating hemodynamic disturbances and recognized complications. With appropriate management, the prognosis for patients with right ventricular infarction is generally favorable.
Captopril renography in the diagnosis of renal artery stenosis and the prediction of improvement with revascularization. The Yale Vascular Center experience.
To enhance diagnosis and predict improvement in blood pressure control following surgery or renal angioplasty in patients with hypertension and renal artery stenosis (RAS), we employed captopril renography in 113 clinically selected patients, all of whom had renal angiography to verify the diagnosis. Criteria for normal captopril renograms were established from an initial cohort of 23 hypertensive patients with normal angiograms who had been judged to be at high risk for RAS using the same clinical criteria. Renal revascularization or nephrectomy was performed in 45 patients and the success of the procedure was determined in the 40 patients for whom 3-month follow-up was available. In these 113 patients, 58 (51%) had RAS. Captopril renography was 91% sensitive and 87% specific in identifying or excluding RAS. Diagnostic utility was preserved in those patients with renal insufficiency (serum creatinine equal to or greater than 1.5 mg/dL) (n = 46). Scintigraphic abnormalities induced by captopril were strongly associated with cure or improvement in blood pressure control following revascularization or nephrectomy (16 of 19), while the lack of captopril-induced change was associated with failure of such intervention (17 of 21) (P = .0001). We conclude that captopril renography is sensitive and specific for the diagnosis of RAS in a clinically selected high-risk group of hypertensives, and that the test accurately predicts the success or failure of therapeutic intervention.
Report of the Working Party Group for Patient Selection and Preparation.
Captopril renography is a valuable test in the diagnosis of patients with renal artery stenosis. We examined the criteria for selecting patients for this procedure and the best methods for preparing the patient for renography.
Antihypertensive drug therapy and regression of left ventricular hypertrophy: a review with a focus on diuretics.
Regression of LVH is a reasonable adjunctive goal of blood pressure treatment, given the well described risks of hypertrophy and the possible benefits inherent in its reversal. Data suggest that any of the presently recommended agents for initial monotherapy, i.e. diuretics, beta adrenergic inhibitors, ACE inhibitors, or calcium blockers, are effective in achieving regression of hypertrophy if blood pressure lowering is achieved. While there may be other factors that play a role in the genesis and maintenance of cardiac hypertrophy in the hypertensive subject, it would appear that blood pressure elevation is probably the most important one. If reduction of blood pressure to normotensive levels can be achieved and maintained by the use of any of the antihypertensive agents (including the vasodilators, if used in combination with adrenergic inhibitors and/or diuretics), there is a reasonable chance that cardiac hypertrophy can be prevented or reversed and prognosis improved.
Simplified captopril renography in diagnosis and treatment of renal artery stenosis.
To improve the diagnosis and forecast the response to surgery or renal angioplasty in patients with hypertension and renal artery stenosis, we employed a simplified captopril renography protocol in conjunction with renal arteriography in 94 clinically selected patients. Fifty hypertensive patients (group 1) with a high clinical likelihood of renovascular hypertension were evaluated using a simplified captopril renography protocol and renal angiography on the arterial side. Criteria for normal captopril renal scintigrams were established based on this original cohort and validated in an additional 44 clinically comparable patients (group 2). Renal revascularization or nephrectomy was performed in 39 patients, and success of the procedure was determined in the 34 patients for whom 3-month follow-up was available. In the 94 patients, 44 (47%) had renal artery stenosis. Simplified captopril renography was 91% sensitive and 94% specific in identifying or excluding renal artery stenosis in the combined group, with no difference in the diagnostic utility between groups 1 and 2, or in those with renal insufficiency (n = 38) or those with bilateral disease (n = 17). Scintigraphic abnormalities induced by captopril were strongly associated with cure or improvement in blood pressure control following revascularization or nephrectomy (15 of 18), while the lack of captopril-induced changes was associated with failure of such intervention (13 of 16) (p = 0.0004). We conclude that simplified captopril renography is highly sensitive and specific in the diagnosis of renal artery stenosis in a clinically selected high-risk population and that the test accurately predicts the success or failure of therapeutic intervention.
Usefulness of verapamil for congestive heart failure associated with abnormal left ventricular diastolic filling and normal left ventricular systolic performance.
Normal left ventricular systolic performance with impaired left ventricular diastolic filling may be present in a substantial number of patients with congestive heart failure (CHF). To evaluate the effect of oral verapamil in this subset, 20 men (mean age 68 +/- 5 years) with CHF, intact left ventricular function (ejection fraction greater than 45%) and abnormal diastolic filling (peak filling rate less than 2.5 end-diastolic volumes per second [edv/s]) were studied in a placebo-controlled, double-blind 5-week crossover trial. All patients underwent echocardiography to rule out significant valvular disease, and thallium-201 stress scintigraphy to exclude major active ischemia. Compared to baseline values, verapamil significantly improved exercise capacity by 33% (13.9 +/- 4.3 vs 10.7 +/- 3.4 minutes at baseline) and peak filling rate by 30% (2.29 +/- 0.54 vs 1.85 +/- 0.45 edv/s at baseline) (all p less than 0.05). Placebo values were 12.3 +/- 4.0 minutes and 2.16 +/- 0.48 edv/s, respectively (difference not significant for both). Improvement from baseline in an objective clinico-radiographic heart failure score (scale 0 to 13) was significantly greater with verapamil compared to placebo (median improvement in score: 3 vs 1, p less than 0.01). Mean ejection fraction and systolic blood pressure were unchanged from baseline; diastolic blood pressure and heart rate decreased to a small degree. Verapamil may have therapeutic efficacy in patients with CHF, preserved systolic function and impaired diastolic filling.
Patients at high risk for renal artery stenosis: a simple method of renal scintigraphic analysis with Tc-99m DTPA and captopril.
Fifty patients with suspected renal artery stenosis (RAS) were studied with renal scintigraphy before and after administration of captopril. Twenty-three patients had RAS (greater than or equal to 75% RAS or greater than or equal to 50% RAS with poststenotic dilatation) and 27 had normal renal arteries at angiography. Angiotensin-converting enzyme inhibitors were discontinued 24 hours prior to renal scintigraphy; all other medications were continued. Each patient was evaluated with a simplified captopril renal scintigraphic protocol: renal imaging after administration of 12 mCi (444 MBq) of technetium-99m diethylenetriaminepentaacetic acid (DTPA), a 3-hour wait, oral administration of 50 mg of captopril, a 1-hour wait, and another scintigram obtained after administration of 12 mCi (444 MBq) of Tc-99m DTPA. Times of peak renal activity (Tmax) were determined from renal time-activity curves, and glomerular filtration rates (GFRs) were calculated with the Gates technique. A Tmax greater than or equal to 11 minutes after injection or a GFR ratio (larger GFR/smaller GFR) greater than 1.5 enabled detection of RAS with 91% sensitivity, 93% specificity, and 92% accuracy. Renal scintigraphy without captopril had only 43%-68% sensitivity in detecting RAS, depending on the criteria used.
Severe Takayasu's arteritis in pregnancy: the role of central hemodynamic monitoring.
Maternal cardiovascular complications have been attributed to the dramatic hemodynamic changes associated with labor and delivery in patients with Takayasu's arteritis. The role of central hemodynamic monitoring in the management of a pregnant patient with severe Takayasu's arteritis is discussed.
Hypertension and neurofibromatosis: secondary causes.
Explore the source record for details and available documents.