Biomedical subjects

Steven E Lipshultz

Publications and source records attributed to Steven E Lipshultz.

48 records · Page 3Linked to original sources

PubMed2003

Cardiac management by pediatricians versus pediatric cardiologists in an inpatient academic center.

BACKGROUND: Limited resources, managed care, and advances in technology have led to the suggestion that physicians other than cardiologists be further empowered to perform the initial cardiac evaluation in children with suspected heart disease. To study this strategy, we compared the management decisions of pediatricians with the recommendations of pediatric cardiologists who reviewed the records of the same patients. METHODS: Sixty-nine patients aged <23 years with suspected heart disease were referred by pediatricians (n = 40) on the inpatient service at Boston Medical Center for either a cardiology consultation or echocardiography. Two pediatric cardiologists who were blinded to the management decisions and clinical outcomes later reviewed the patient records. Recommendations between the 2 pediatric cardiologist reviewers and the managing pediatricians were compared. RESULTS: Pediatricians scheduled significantly fewer cardiology follow-up visits, instituted cardiac medications significantly less often, arranged significantly fewer family meetings to review cardiac findings, and ordered significantly fewer additional cardiac procedures than the pediatric cardiologists. This result was consistent regardless of whether the pediatrician's management decisions were made on the basis of the echocardiogram results only or on the recommendations of a cardiology consultant. The 2 pediatric cardiologist reviewers agreed more often with each other than either did with the managing pediatricians. CONCLUSIONS: Pediatricians have different management styles than pediatric cardiologists for patients with suspected cardiac disease. The effect of these differences on outcome is unknown, and further investigation is warranted.

Academic Medical Centers↗

PubMed2003

Cardiomyocyte injury to transplant: pediatric management.

Cardiomyocyte injury in pediatric patients has a vast number of causes, which are often distinct from the causes of adult heart failure. However, the management of pediatric heart failure and heart transplantation has generally been inferred from adult studies. New therapies show great promise for the neurohormonal regulation of heart failure and the ability to control immunosuppression after heart transplantation. Large, randomized, multicenter, controlled clinical trials are needed to determine the efficacy of these therapies in this population. This article reviews the current recommendations and evidence-based medicine, where available, for the medical management of myopathic dysfunction and transplantation in pediatric patients.

Adrenergic beta-Antagonists↗

PubMed2003

Mediators in HIV-associated cardiovascular disease: a focus on cytokines and genes.

As longevity increases in HIV-infected individuals, late effects such as cardiovascular disease and, more specifically, symptomatic heart failure are emerging as leading health issues. In the present review, we discuss possible cytokine and gene-mediated effects on HIV-associated cardiovascular illness that may play a role in diagnosis, management, and therapy of HIV-associated heart failure.

AIDS Dementia Complex↗

PubMed2003

Cardiovascular risk factors, monitoring, and therapy for HIV-infected patients.

Cardiovascular complications are important contributors to morbidity and mortality in HIV-infected patients. These complications can usually be detected at subclinical levels with monitoring, which can help guide targeted interventions. This article reviews available data on types and frequency of cardiovascular manifestations in HIV-infected patients and proposes monitoring strategies aimed at early subclinical detection. In particular, we recommend routine echocardiography for HIV-infected patients, even those with no evidence of cardiovascular disease. We also review preventive and therapeutic cardiovascular interventions. For procedures that have not been studied in HIV-infected patients, we extrapolate from evidence-based guidelines for the general population.

Anti-Infective Agents↗

PubMed2003

Serum cardiac troponin and subclinical cardiac status in pediatric chronic renal failure.

BACKGROUND: Patients with uremia often have elevated serum cardiac troponin T (cTnT) even without clinical heart damage. Pediatric patients are ideal for studies of the relationship between uremia and heart disease because they are unlikely to have cardiac risk factors other than uremia. OBJECTIVE: To determine the relationship between uremia and cTnT levels. DESIGN: Echocardiograms and blood chemistry results were obtained from 50 pediatric patients with chronic renal failure and without clinical heart disease. Levels of cTnT were tested for correlation with cardiac dysfunction. In multivariate analysis, biochemical aspects of renal disease and its treatment were tested for correlation with cardiac dysfunction. RESULTS: Forty-nine patients had cardiovascular abnormalities, including increased left ventricular function and mass, elevated heart rate and blood pressure, and reduced LV afterload. LV contractility was inversely correlated with cTnT level (r = -0.36). Higher cTnT also correlated with higher serum creatine kinase-MB mass, lower serum parathyroid hormone, higher blood urea nitrogen and bicarbonate levels, and the use of diuretics, but not with higher cardiac troponin I. Left ventricular contractility was inversely related to serum creatinine, phosphorus, and the use of beta-blockers. CONCLUSIONS: Elevated cTnT levels are not artifactual, but are genuine indicators of cardiomyocyte damage. Cardiac damage, indicated by either elevated cTnT or low LV contractility, is related to uremia, deranged calcium and phosphorus metabolism, and bicarbonate levels. Serum cTnT and LV contractility identify subclinical cardiac damage that could be treated to hopefully reduce cardiovascular morbidity and mortality in this high-risk population.

Adolescent↗

PubMed2002

Long-term enalapril therapy for left ventricular dysfunction in doxorubicin-treated survivors of childhood cancer.

PURPOSE: A common late effect of doxorubicin therapy for childhood cancer is reduced left-ventricular (LV) wall thickness resulting in elevated LV afterload and depressed LV function. Many children are given angiotensin-converting enzyme inhibitors, which have been studied primarily in adults. We document the long-term effects of angiotensin-converting enzyme inhibitors in doxorubicin-treated survivors of childhood cancer. PATIENTS AND METHODS: In this retrospective study, we reviewed records of 18 children who had regular echocardiographic examinations during enalapril therapy (mean age at cancer diagnosis, 8 years; mean time between completion of doxorubicin therapy and start of enalapril, 7 years; median follow-up since the start of enalapril, 10 years). RESULTS: Over the first 6 years of enalapril therapy, there was progressive improvement toward normal values in LV dimension, afterload, fractional shortening, and mass, but all these parameters deteriorated between 6 and 10 years. LV wall thickness deteriorated throughout the study period, as did LV contractility and systolic blood pressure. Diastolic blood pressure fell slightly. By 6 years on enalapril, all six patients who had had congestive heart failure at the start of enalapril therapy had either died or undergone cardiac transplantation, compared with three of the 12 asymptomatic patients. CONCLUSION: In doxorubicin-treated long-term survivors of childhood cancer, enalapril-induced improvement in LV structure and function is transient. The primary defect, which is LV wall thinning, continues to deteriorate, and thus the short-term improvement was mostly related to lowered diastolic blood pressure.

Adolescent↗

PubMed2002

Cardiovascular status of infants and children of women infected with HIV-1 (P(2)C(2) HIV): a cohort study.

BACKGROUND: Data from cross-sectional and short-term longitudinal studies have suggested that children infected with HIV-1 might have cardiovascular abnormalities. We aimed to investigate this hypothesis in a long-term cohort study. METHODS: We measured cardiovascular function every 4-6 months for up to 5 years in a birth cohort of 600 infants born to women infected with HIV-1. We included 93 infants infected with HIV-1 and 463 uninfected infants (internal controls) from the same cohort. We also included a cross-sectionally measured comparison group of 195 healthy children born to mothers who were not infected with HIV-1 (external controls). FINDINGS: Children infected with HIV-1 had a significantly higher heart rate at all ages (mean difference 10 bpm, 95% CI 8-13) than internal controls. At birth, both cohort groups of children had similar low left ventricular (LV) fractional shortening. At 8 months, fractional shortening was similar in internal and external controls, whereas in children infected with HIV-1, fractional shortening remained significantly lower than in controls for the first 20 months of life (mean difference from internal controls at 8 months 3.7%, 2.3-5.1). LV mass was similar at birth in both cohort groups, but became significantly higher in children with HIV-1 from 4-30 months (mean difference 2.4 g at 8 months, 0.9-3.9). CONCLUSIONS: Vertically-transmitted HIV-1 infection is associated with persistent cardiovascular abnormalities identifiable shortly after birth. Irrespective of their HIV-1 status, infants born to women infected with HIV-1 have significantly worse cardiac function than other infants, suggesting that the uterine environment has an important role in postnatal cardiovascular abnormalities.

Cardiovascular Abnormalities↗

PubMed2002

Evaluation of coxsackievirus infection in children with human immunodeficiency virus type 1-associated cardiomyopathy.

In a matched case-control study of the association between coxsackieviruses and cardiac impairment, 24 human immunodeficiency virus (HIV) type 1-infected children with cardiac impairment were compared with 24 HIV-1-infected control subjects. Serologic evidence of coxsackievirus infection was present in all children, with no significant difference in geometric mean antibody titers between case patients and control subjects. Conditional logistic regression to test for an association between coxsackievirus antibody titer and the presence or absence of cardiac impairment, by any indicator, showed an odds ratio of 1.11 (95% confidence interval, 0.58-2.10; P=.75), indicating no association between coxsackievirus infection and cardiac impairment. Coxsackievirus antibody titers correlated positively with total IgG levels in nonrapid progressors but not in rapid progressors. Paired serum samples taken before and after diagnosis of cardiac impairment in 5 patients showed no evidence of intervening coxsackievirus infection. These results do not identify a causal role for coxsackieviruses for cardiomyopathy in HIV-1-infected children.

Cardiomyopathies↗

PubMed2002

Doxorubicin administration by continuous infusion is not cardioprotective: the Dana-Farber 91-01 Acute Lymphoblastic Leukemia protocol.

PURPOSE: Acute doxorubicin-induced cardiotoxicity can be prevented in adults by continuous infusion of the drug, but mechanisms of cardiotoxicity are different in children. We compared cardiac outcomes in children receiving bolus or continuous infusion of doxorubicin. PATIENTS AND METHODS: In a randomized study, children with high-risk acute lymphoblastic leukemia received doxorubicin 360 mg/m(2) in 30-mg/m(2) doses every 3 weeks either by bolus (within 1 hour, n = 57) or by continuous infusion (over 48 hours, n = 64). Echocardiograms obtained before doxorubicin and at longest follow-up times were centrally remeasured, and z scores of cardiac measurements were calculated based on a healthy population. RESULTS: The groups were similar in age, sex distribution, doxorubicin dose, and duration of follow-up. Before treatment, measures of left ventricular (LV) structure and function did not reveal dilated cardiomyopathy and were not statistically different between bolus and continuous-infusion groups. The follow-up echocardiograms demonstrated no significant difference between the two groups for any cardiac characteristic, but both groups showed significant abnormalities of LV structure and function compared with normal and with baseline. For example, the mean LV fractional shortening fell by approximately two SD in both groups between the two echocardiograms. LV contractility was depressed in both groups (for bolus patients, median z score = -0.70 SD, P =.006; for continuous-infusion patients, median z score = -0.765, P =.005). Dilated cardiomyopathy and inadequate LV hypertrophy were noted in both groups. Clinical cardiac manifestations and event-free survival did not differ. CONCLUSION: Continuous doxorubicin infusion over 48 hours for childhood leukemia did not offer a cardioprotective advantage over bolus infusion. Both regimens were associated with progressive subclinical cardiotoxicity. Other cardioprotective strategies should be explored.

Adolescent↗

PubMed2002

Treatment of childhood acute lymphoblastic leukemia: results of Dana-Farber ALL Consortium Protocol 87-01.

PURPOSE: To improve efficacy and reduce toxicity of treatment for children with acute lymphoblastic leukemia. PATIENTS AND METHODS: Patients from all risk groups, including infants and those with T-cell disease, were treated between 1987 and 1991. Standard-risk (SR) patients did not receive cranial irradiation, whereas high-risk (HR) and very high-risk (VHR) patients participated in a randomized comparison of 18 Gy of cranial irradiation conventionally fractionated versus two fractions per day (hyperfractionated). RESULTS: At a median follow-up of 9.2 years, the 9-year event-free survival (EFS +/- SE) was 75% +/- 2% for all 369 patients, 77% +/- 4% for the 142 SR patients, and 73% +/- 3% for the 227 HR/VHR patients (P =.37 comparing SR and HR/VHR). The CNS, with or without concomitant bone marrow involvement, was the first site of relapse in 19 (13%) of the 142 SR patients: 16 (20%) of 79 SR boys and three (5%) of 63 SR girls. This high incidence of relapses necessitated a recall of SR boys for additional therapy. CNS relapse occurred in only two (1%) of 227 HR and VHR patients. There were no outcome differences found among randomized treatment groups. Nine-year overall survival was 84% +/- 2% for the entire population, 93% +/- 2% for SR children, and 79% +/- 3% for HR and VHR children (P <.01 comparing SR and HR/VHR). CONCLUSION: A high overall survival outcome was obtained for SR patients despite the high risk of CNS relapse for SR boys, which was presumed to be associated with eliminating cranial radiation without intensifying systemic or intrathecal chemotherapy. For HR/VHR patients, inability to salvage after relapse (nearly all of which were in the bone marrow) remains a significant clinical problem.

Adolescent↗

PubMed2002

Incidence of cardiac abnormalities in children with human immunodeficiency virus infection: The prospective P2C2 HIV study.

OBJECTIVE: To describe the 5-year cumulative incidence of cardiac dysfunction in human immunodeficiency virus (HIV)-infected children. STUDY DESIGN: We used a prospective cohort design, enrolling children at 10 hospitals. Group I included 205 vertically HIV-infected children enrolled at a median age of 1.9 years. Group II consisted of 600 HIV-exposed children enrolled prenatally or as neonates, of whom 93 were ultimately HIV-infected. The main outcome measures were echocardiographic indexes of left ventricular dysfunction. RESULTS: In group I, the 5-year cumulative incidence of left ventricular fractional shortening </=25% was 28.0%. The 5-year incidence of left ventricular end-diastolic dilatation was 21.7%, and heart failure and/or the use of cardiac medications 28.8%. The mortality rate 1 year after the diagnosis of heart failure was 52.5% [95% CI, 30.5-74.5]. Within group II, the 5-year cumulative incidence of decreased fractional shortening was 10.7% in the HIV-infected compared with 3.1% in the HIV-uninfected children (P =.01). Left ventricular dilation, heart failure, and/or the use of cardiac medications were more common in infected compared with uninfected children. CONCLUSIONS: During 5 years of follow-up, cardiac dysfunction occurred in 18% to 39% of HIV-infected children and was associated with an increased risk of death. We recommend that HIV-infected children undergo routine echocardiographic surveillance for cardiac abnormalities.

Disease Progression↗

PubMedDate not supplied

Postmortem cardiomegaly and echocardiographic measurements of left ventricular size and function in children infected with the human immunodeficiency virus. The Prospective P2C2 HIV Multicenter Study.

BACKGROUND: Cardiomegaly, seen postmortem in over 50% of HIV-infected children, may occur in the absence of clinical or histopathologic cardiac disease. Premortem echocardiography has also demonstrated clinical and subclinical cardiac disease, including increased left ventricular mass (LVM) and functional abnormalities. No studies have compared these echocardiographic measures of heart size and function with postmortem findings in this population. We sought to determine the postmortem prevalence, clinicopathologic relationships and importance of cardiomegaly in HIV-infected children. METHODS: We reviewed clinical and postmortem cardiac findings in 30 HIV-infected children who were part of the Prospective P(2)C(2) HIV Study. Postmortem heart weight was compared with clinical measures of heart size and function, with cardiac pathology and with clinical measures reflecting chronic effects of HIV disease. RESULTS: Postmortem cardiomegaly (heart weight z score >/=2) was identified in 53% of the children. Children with cardiomegaly had increased LVM, increased heart rate, more frequent clinical chronic heart disease and a higher prevalence of postmortem pericardial effusions compared to children without cardiomegaly (P</=.05). The association with LV end-diastolic dimension (LVEDD) did not reach statistical significance (P=.08). No association was found with LV posterior wall thickness (LVPWT), CD4(+) T-cell counts, HIV-1 viral load, hemoglobin, encephalopathy, myocardial histology or myocardial organisms. CONCLUSIONS: Postmortem cardiomegaly was associated with echocardiographic measures of increased LVM. The pathogenesis appears not to be related to chronic anemia, HIV viral load, the degree of immune suppression or encephalopathy. Autonomic dysregulation, reflected by chronically increased heart rate, may be of pathoetiologic significance.

Child↗