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PubMed1996

Congestive heart failure with normal left ventricular systolic function. Clinical approaches to the diagnosis and treatment of diastolic heart failure.

The syndrome of congestive heart failure with preserved left ventricular systolic function is common in clinical practice. The signs and symptoms of the disorder are similar to those of congestive heart failure with left ventricular systolic dysfunction, underscoring a need for routine evaluation of left and right ventricular systolic function in patients with congestive heart failure. The syndrome may be related to anatomic abnormalities that increase the resistance to ventricular filling, or to physiologic abnormalities of myocardial relaxation or compliance. Advancing age, often in association with hypertension, coronary artery disease, tachycardia, and atrial fibrillation, is commonly associated with the disorder. Randomized controlled clinical trials are needed to evaluate the efficacy of various therapeutic agents in reducing the risks associated with diastolic heart failure.

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PubMed2000

The acute effects of transvenous biventricular pacing in a patient with congestive heart failure.

The management of congestive heart failure remains an issue of great interest. Encouraging data emerged over the last 2 years supporting the use of multisite pacing in patients with severe congestive heart failure and intraventricular conduction delay. We present a case of acute biventricular pacing in a 81-year old man with dilated cardiomyopathy and symptomatic congestive heart failure. This novel form of pacemaker treatment resulted in a rapid hemodynamic and clinical improvement.

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PubMed1988

Body fluid homeostasis in the newborn infant with congestive heart failure: effects of diuretics.

Congestive heart failure is characterized by extracellular fluid volume expansion, increased venous filling pressure, and paradoxal renal sodium retention. Although diuretics remain invaluable agents to lower venous pressure in congestive heart failure, they also carry the risk of further compromising cardiac output and inducing severe adverse effects. This article reviews the pathophysiology of body fluid homeostasis in neonates with congestive heart failure, and discusses the adverse effects associated with the use and abuse of diuretics.

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PubMed1988

Changes in atrial natriuretic factor during preload reduction with nitroglycerin in patients with congestive heart failure.

Nine patients with congestive heart failure, New York Heart Association class II-III, were evaluated with right heart catheterization. Plasma atrial natriuretic factor (ANF) was determined in blood samples from the pulmonary artery simultaneously with recordings of right atrial, pulmonary arterial, pulmonary capillary wedge and systemic arterial pressures and heart rate during preload reduction with 0.5 mg nitroglycerin sublingually. Basal plasma ANF levels were higher in patients with congestive heart failure compared to normal controls, and correlated to right atrial, pulmonary arterial, and pulmonary capillary wedge pressures. After nitroglycerin all patients had reductions in right atrial, pulmonary arterial, and pulmonary capillary wedge pressures and a simultaneous decrease in plasma ANF concentrations, reaching lowest values after 10 min. Central pressures and plasma ANF rose to baseline values within 30 min. After nitroglycerin plasma ANF concentrations correlated to pulmonary arterial and pulmonary capillary wedge pressures, while changes in plasma ANF correlated to changes in right atrial and pulmonary arterial pressures. These results provide further evidence that ANF is released by a pressure-sensitive mechanism and demonstrates that ANF secretion in relation to central pressure variations is preserved in patients with congestive heart failure and that the response is rapid.

Adult↗
PubMed1999

Correlation of the Agency for Health Care Policy and Research congestive heart failure admission guideline with mortality: peer review organization voluntary hospital association initiative to decrease events (PROVIDE) for congestive heart failure.

STUDY OBJECTIVE: We quantify patient risk as related to the presence or absence of the Agency for Health Care Policy and Research (AHCPR) congestive heart failure (CHF) hospital admission criteria. METHODS: This was a retrospective observational cohort study at 12 acute care hospitals examining consecutive patients with the final primary diagnosis of CHF. Trained record abstractors blinded to outcome extracted 386 data elements, including 6 AHCPR admission criteria: (1) pulmonary edema (determined by radiograph) or severe respiratory distress (respiration >40 breaths/min), (2) hypoxia (oxygen saturation <90%) not caused by pulmonary disease, (3) significant edema (>/=+2) or anasarca, (4) symptomatic hypotension (<90 mm Hg systolic blood pressure) or syncope, (5) CHF of recent onset, and (6) clinical evidence (chest pain) of myocardial ischemia. The association between admission criteria and mortality rate (30 days, 6 months, and 1 year) was quantified and risk adjusted by stepwise logistic regression analysis. RESULTS: Of the 1,674 patients with CHF, 1,340 (80%) were admitted to the hospital. Patients not admitted had a lower mortality rate than admitted patients (30-day mortality rate, 2.1% [95% confidence interval [CI] 0.6 to 3.6] versus 11.5% [95% CI 9.8 to 13.2]; odds ratio 0.20 [95% CI 0.09 to 0.45]). Two of the admission criteria did not correlate with a higher mortality rate: CHF of recent onset and myocardial ischemia. Excluding those 2 criteria, the number of admission criteria present correlated with the patient's probability of hospital admission (P <.001), length of hospital stay (P =.014), and 30-day mortality rate (P <.0001). When zero or 1 admission criteria was present, physician clinical judgment did distinguish patients less likely to die in the subsequent 30 days (1.5% [95% CI 0.2 to 2.8] sent home versus 10.2% [95% CI 8.5 to 11.9] admitted). When 2 or more admission criteria were present, physician clinical judgment did not distinguish patients less likely to die in the subsequent 30 days (18.2% [95% CI 0 to 42.0] sent home versus 19.4% [95% CI 13.6 to 25.2] admitted). CONCLUSION: Selected criteria of the AHCPR CHF admission guideline correlate with mortality rate. Combined with physician clinical judgment, they may be useful in the risk stratification of patients with CHF. Selected low-risk patients with CHF identified by the admission criteria who are presently managed in the acute care hospital may be candidates for outpatient management. [Graff L, Orledge J, Radford MJ, Wang Y, Petrillo M, Maag R: Correlation of the Agency for Health Care Policy and Research congestive heart failure admission guideline with mortality: Peer Review Organization Voluntary Hospital Association Initiative to Decrease Events (PROVIDE) for congestive heart failure.

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PubMed1988

Responsiveness of atrial natriuretic factor to reduction in right atrial pressure in patients with chronic congestive heart failure.

In patients with congestive heart failure, atrial natriuretic factor may serve as a counter-regulatory hormone, offsetting the vasoconstrictive and volume-retentive effects of the sympathetic nervous system, the renin-angiotensin-aldosterone system and vasopressin. Indeed, the plasma levels of atrial natriuretic factor and the vasoconstrictor hormones are often simultaneously elevated in these patients. It is not known, however, whether atrial natriuretic factor remains responsive to sudden reductions in atrial pressure in patients with chronic heart failure, or is unresponsive like the vasoconstrictor systems. To examine this issue, the plasma concentrations of atrial natriuretic factor and the vasoconstrictor hormones were measured in 20 normal subjects and 12 patients with chronic congestive heart failure during incremental lower body negative pressure, an intervention that lowers atrial pressure. In the normal subjects, incremental lower body negative pressure at -10, -20 and -40 mm Hg decreased central venous pressure and pulse pressure. At maximal lower body negative pressure, plasma atrial natriuretic factor levels decreased from 51 +/- 5 to 27 +/- 3 pg/ml (p less than 0.01), whereas increases occurred in plasma levels of norepinephrine (194 +/- 11 to 385 +/- 70 pg/ml, p less than 0.01), renin activity (1.4 +/- 0.2 to 3.9 +/- 0.1 ng/ml per h, p less than 0.01) and vasopressin (1.3 +/- 0.1 to 6.4 +/- 2.4 pg/ml, p less than 0.05). In the patients with congestive heart failure, lower body negative pressure also reduced central venous pressure. Baseline plasma atrial natriuretic factor levels were markedly elevated, averaging 438 +/- 138 pg/ml, and decreased to 317 +/- 87 pg/ml at maximal lower body negative pressure (p less than 0.05).(ABSTRACT TRUNCATED AT 250 WORDS)

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PubMed1990

Role of angiotensin-converting enzyme inhibitors in congestive heart failure.

Conventional therapy for congestive heart failure (CHF) includes sodium-restricted diet, diuretics, digitalis, vasodilators, and short-term intravenous administration of beta-adrenergic agonists during episodes of decompensation. A specific class of vasodilators, the angiotensin-converting enzyme inhibitors, has recently gained predominance in the treatment of congestive heart failure. The primary mechanism of action is to reduce production of angiotensin II by competitive inhibition of the enzyme that converts angiotensin I into angiotensin II. Reduced levels of angiotensin II, in turn, promote vasodilation and lower aldosterone production. The benefits of angiotensin-converting enzyme inhibitor therapy in chronic congestive heart failure have been demonstrated by improvement in left ventricular performance, exercise capacity, functional status (using New York Heart Association classification), and survival.

Angiotensin-Converting Enzyme Inhibitors↗
PubMed1988

Sequential neurohumoral measurements in patients with congestive heart failure.

Patients with chronic congestive heart failure are known to have increased plasma norepinephrine and plasma renin activity. In order to evaluate neurohumoral changes over time, we measured plasma norepinephrine and plasma renin activity at baseline and sequentially during follow-up in 49 patients with chronic, stable congestive heart failure. All patients were treated with digitalis and diuretics. Converting enzyme inhibitor therapy was prescribed as adjunctive therapy in 22 patients, while 10 patients were taking hydralazine and/or isosorbide dinitrate, seven were taking prazosin, and 10 had no adjunctive therapy. Patients were divided into those taking converting enzyme inhibitors (group I, n = 22) and those not taking converting enzyme inhibitors (group II, n = 27). Group I was followed for a median (25th to 75th percentiles) of 24.3 (18 to 27.9) months, while group II was followed for 18.7 (11.9 to 36.5) months. Results indicate that patients in group I demonstrate a significant positive trend for rise in plasma norepinephrine of 11.7 pg/ml per month (7.8 to 15 pg/ml per month, 95% confidence interval). Patients in group II also demonstrated a significant positive trend in plasma norepinephrine over time of 6.6 pg/ml per month (2.2 to 11.1 pg/ml per month). Moreover, there was a progressive trend upward in plasma renin activity over time in group II (median 0.34 ng/ml/hr per month; range 0.13 to 0.54). The data indicate that there is a significant trend of neurohumoral activation over time in patients with chronic, clinically stable congestive heart failure.(ABSTRACT TRUNCATED AT 250 WORDS)

Angiotensin-Converting Enzyme Inhibitors↗
PubMedDate not supplied

Congestive heart failure and continuous positive airway pressure therapy: support of a new modality for improving the prognosis and survival of patients with advanced congestive heart failure.

Nasal continuous positive airway pressure therapy has recently been studied as a nonpharmacologic adjunct to congestive heart failure therapy. In patients with congestive heart failure, it was reported that continuous positive airway pressure therapy for the condition Cheyne-Stokes respiration with central sleep apnea led to long-term improvements in cardiac function and alleviation of heart failure symptoms. Cheyne-Stokes respiration with central sleep apnea is a frequent breathing disorder well described in patients with congestive heart failure, and is an associated risk factor for increased cardiovascular morbidity and mortality. These apneas cause an increase in sympathetic nervous system activity, which would maintain afterload at a high level or tend to increase it with time, leading to further compromise of ejection fraction. Continuous positive airway pressure appears to benefit the failing heart by increasing intrathoracic pressure, which is believed to cause an increase in cardiac output by decreasing the pressure gradient across the heart wall and allowing the left-ventricular end diastolic volume to decrease, thereby reducing the afterload. This beneficial "resting" of the heart has been documented to increase left-ventricular ejection fraction, increase cardiac index, improve inspiratory muscle strength, lower blood pressure and heart rate, decrease plasma and overnight urinary levels of norepinephrine, lower levels of atrial natriuretic peptide and endothelin-1, and increase heart rate variability. Other benefits include improvement in New York Heart Association functional class status and improvement in dyspnea.

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PubMed1997

Readmission after hospitalization for congestive heart failure among Medicare beneficiaries.

BACKGROUND: Congestive heart failure is the most common discharge diagnosis for Medicare beneficiaries. While several single-center studies have suggested that these patients are particularly vulnerable to readmission, no recent study, to our knowledge, has reported the readmission rates for a large number of elderly patients with congestive heart failure across a diverse spectrum of hospitals. OBJECTIVES: To define the readmission rate for elderly patients discharged after an episode of congestive heart failure. To determine the spectrum of diagnoses that are responsible for readmissions among patients with congestive heart failure. To identify patient and hospital characteristics associated with a higher likelihood of readmission. METHODS: This observational study, using Medicare administrative files, evaluated readmission and death among all survivors of a hospitalization in Connecticut for congestive heart failure from fiscal year 1991 through fiscal year 1994. RESULTS: There were 17448 survivors of a hospitalization for congestive heart failure during the study period. In the 6 months following the index admission, 7596 patients (44%) were readmitted to a hospital at least once. Congestive heart failure was the most frequent reason for readmission among study patients, accounting for 18% of all readmissions. In the multivariable analysis, significant predictors of readmission included male sex (odds ratio [OR], 1.12; 95% confidence interval [CI], 1.05-1.20), at least 1 prior admission within 6 months of the index admission (OR, 1.64; 95% CI, 1.53-1.77), Deyo comorbidity score of more than 1 (OR, 1.56; 95% CI, 1.45-1.68), and length of stay in the index hospitalization of more than 7 days (OR, 1.32; 95% CI, 1.24-1.41). While age was not a significant predictor of readmission, it became significant in a model with the combined outcome of readmission or death as the dependent variable. CONCLUSION: Readmission after a hospitalization for congestive heart failure is common among Medicare beneficiaries, with almost half of the patients readmitted within 6 months. This striking rate of readmission in a common diagnosis demands efforts to further clarify the determinants of readmission and develop strategies to prevent this adverse outcome.

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PubMed1994

Chronic congestive heart failure. Description and survival of 190 consecutive patients with a diagnosis of chronic congestive heart failure based on clinical signs and symptoms.

The prognosis, and clinical findings related to prognosis, were examined in a consecutive series of 190 patients under 76 years of age (mean 64 years) with congestive heart failure (CHF). The aetiology of CHF was ischaemic heart disease in 66%, hypertension in 11% and cardiomyopathy in 23%. The 2-year mortality was 32%. Median left ventricular ejection fraction (LVEF) was 0.30, range 0.06 to 0.74. Eight per cent were in New York Heart Association (NYHA) class I, 46% in II, 44% in III and 2% in IV. Multivariate analysis, excluding exercise test variables, revealed seven variables with independent, significant prognostic information, (hazard ratios for death in brackets): ln (natural logarithm) (LVEF) (3.19), NYHA class III+IV (2.72), plasma urea > 7.6 mmol.l-1 (2.22), serum creatinine > 121 mumol.l-1 (2.05), serum sodium < or = 137 mmol.l-1 (2.03), pulmonary congestion on X-ray (1.86), and age > 65 years (1.86). Multivariate analysis, including exercise testing, showed the following variables to contain independent, significant prognostic information: increase in heart rate during maximal exercise < or = 35 min-1 (3.5), ln (LVEF) (3.7), serum creatinine > 121 mumol.l-1 (2.9), maximal exercise time < or = 4 min (2.3), serum sodium < or = 137 mmol.l-1 (2.5), ischaemic heart disease (2.0) and plasma urea > 7.6 mmol.l-1 (1.9). In conclusion, patients with CHF have a high risk of death despite intensive medical treatment. LVEF is a strong predictor of mortality. Both NYHA class and exercise variables have strong independent prognostic information as regards mortality in combination with LVEF, but are mutually exclusive.

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PubMed1981

Congestive heart failure.

The prevalence of congestive heart failure increases as the population ages. Conventional treatment of congestive heart failure is usually applied to persons over 60 with heart failure; yet very little is known concerning the cardiovascular alterations induced by aging. Animal experiments have indicated that presbycardia as a distinctive entity does exist but that it does not, in and of itself, cause heart failure in large numbers of individuals. The main causes remain the same as those in the younger population (i.e. ischemic and hypertensive disease). Diagnosis is altered in aged individuals because symptoms and signs may not be those classically described and taught. Pharmacologic treatment is hampered by a decreased responsiveness to inotropic agents, while toxicity levels are probably not altered. Although vasodilators may theoretically promote more satisfactory results, their clinical effectiveness and potential toxicities in elderly patients have not been evaluated.

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PubMed2004

The association between congestive heart failure and chronic renal disease.

PURPOSE OF REVIEW: Recent findings on the relationship between congestive heart failure and renal failure are summarized in this review. RECENT FINDINGS: Congestive heart failure is found in about one-quarter of cases of chronic kidney disease. The most common cause of congestive heart failure is ischemic heart disease. The prevalence of congestive heart failure increases greatly as the patient's renal function deteriorates, and, at end-stage renal disease, can reach 65-70%. There is mounting evidence that chronic kidney disease itself is a major contributor to severe cardiac damage and, conversely, that congestive heart failure is a major cause of progressive chronic kidney disease. Uncontrolled congestive heart failure is often associated with a rapid fall in renal function and adequate control of congestive heart failure can prevent this. The opposite is also true: treatment of chronic kidney disease can prevent congestive heart failure. There is new evidence showing the cardioprotective effect of carvedilol in patients on dialysis, and of simvastatin and eplerenone in patients with congestive heart failure. Use of non-steroidal anti-inflammatory drugs doubles the rate of hospitalization in patients with congestive heart failure. Anemia has been found in one-third to half the cases of congestive heart failure, and may be caused not only by chronic kidney disease but by the congestive heart failure itself. The anemia is associated with worsening cardiac and renal status and often with signs of malnutrition. Control of the anemia and aggressive use of the recommended medication for congestive heart failure may improve the cardiac function, patient function and exercise capacity, stabilize the renal function, reduce hospitalization and improve quality of life. Congestive heart failure, chronic kidney disease and anemia therefore appear to act together in a vicious circle in which each condition causes or exacerbates the other. Both congestive heart failure and anemia are often undertreated. Cooperation between nephrologists and other physicians in the treatment of patients with anemic congestive heart failure may improve the quality of care and the subsequent prognosis for both congestive heart failure and chronic kidney disease. SUMMARY: Adequate and early detection and aggressive treatment of congestive heart failure and chronic kidney disease and the associated anemia may markedly slow the progression of both diseases.

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