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PubMedDate not supplied

Effect of left and right lateral decubitus positions on Doppler mitral flow patterns in patients with severe congestive heart failure.

Patients with severe congestive heart failure (SCHF) complain of increasing dyspnea when adopting left lateral decubitus (LLD) position that improves when turning over to the right lateral decubitus (RLD) position (trepopnea). We hypothesize that this clinical sign is due to changes in left ventricular (LV) preload and such changes would modify mitral flow. This study analyzes the effect of RLD and LLD positions on LV filling pattern assessed by Doppler echocardiography in patients with SCHF. Seventeen men and seven women (aged 56.22 +/- 18.52 years) with SCHF in New York Heart Association functional class III-IV and nine normal control subjects (eight men and one woman aged 56.96 +/- 18.14 years) were studied. We analyzed early (E) and late (A) LV filling velocities, E/A ratios, deceleration time, mitral time-velocity integral in each decubitus position, and the differences between them. Patients with SCHF have smaller mitral time-velocity integral, shorter deceleration time, greater E velocity and E/A ratio, and lower A velocity in LLD position than do normal control subjects. On assuming RLD position, patients with SCHF show decreases in E velocity and E/A ratio and lengthening of the deceleration time, suggesting a decrease in LV preload on changing position. This pathophysiologic mechanism may explain why patients with SCHF willingly adopt RLD position.

Adult↗

PubMed2000

An animal model of arrhythmogenesis in congestive heart failure.

Background: Patients with congestive heart failure (CHF) frequently die from arrhythmias, but models to study arrhythmogenic mechanisms during progressive CHF are lacking. Consequently we examined the feasibility of using dogs with an ischemic insult followed by rapid pacing to study ventricular arrhythmias in CHF. Methods: Eighteen chronically instrumented dogs had ischemic damage induced by inflating a balloon tipped catheter in a coronary artery for 90 min. After 2 weeks recovery, electrophysiologic studies were performed on no drugs, during esmolol infusion, and during isoproterenol infusion. The pacer was turned on at 250 bpm in 12 dogs, but not in six controls, and studies repeated bi-weekly for up to 6 weeks. Results: Serial echocardiograms documented progressive CHF, and serial signal averaged electrocardiograms demonstrated prolongation of total QRS, increased duration of terminal QRS<40 mv, and decreased RMS voltage of the terminal 20 ms of QRS in paced dogs. Arrhythmia severity increased as CHF progressed, but responses were quite variable, unaffected by esmolol, and minimally altered by isoproterenol. Conclusions: Ischemic left ventricular damage followed by rapid ventricular pacing in dogs produces a model that closely mimics patients with CHF and ventricular arrhythmias, including a heterogeneous pathophysiologic response to intervention.

Journal Article↗

PubMedDate not supplied

The measurement of extravascular lung density with SPECT imaging and its relationship with ventilatory abnormalities in patients with congestive heart failure.

BACKGROUND: Patients with congestive heart failure (CHF) have increased ventilatory equivalent for carbon dioxide (Ve/VCO(2)), which may contribute to the symptom of exercise-induced hyperpnea. We have developed a technique in which simultaneous blood volume single photon emission computed tomography imaging and transmission tomography are used to measure extravascular lung density (ELD). We investigated the correlation between Ve/VCO(2) and ELD in patients with CHF. METHODS AND RESULTS: Thirteen patients with stable CHF and eleven control subjects were studied. Attenuation-corrected blood volume emission tomography was acquired with simultaneous transmission tomography to measure pulmonary blood volume and total lung density, respectively. Seven CHF patients underwent maximal exercise treadmill testing with online respiratory gas analysis. ELD was calculated as total lung density minus pulmonary blood volume. SPECT and transmission tomography were repeated immediately after exercise. CHF patients had significantly higher total lung density and ELD compared with normal subjects. No differences in pulmonary blood volume were observed. There was a significant inverse correlation between ELD and left ventricular ejection fraction at rest in CHF patients (r = -0.77, P <.001). A strong correlation was also found between post-exercise ELD and Ve/VCO(2) at peak exercise (r = 0.74, P =.008) and at anaerobic threshold (r = 0.67, P =.024). CONCLUSION: Patients with chronic CHF have increased ELD. The correlation between ELD and Ve/VCO(2) suggests that increased lung water may contribute to the ventilatory abnormalities seen in patients with CHF.

Absorptiometry, Photon↗

PubMedDate not supplied

Acute congestive heart failure: preventing complications.

Acute congestive heart failure (CHF) is a common clinical problem with a serious prognosis for the patient. For acute care hospitals, it is also the number one "money loser" for its diagnostic related group. For these reasons, it is important to understand how the critical care nurse can implement nursing measures and work within a multidisciplinary team to prevent complications in CHF patients. This article identifies the determinants of myocardial performance and nursing interventions that help lessen or prevent complications in CHF patients.

Acute Disease↗

PubMed2004

Managing congestive heart failure using home telehealth.

Congestive heart failure (CHF) is the leading cause of rehospitalization and loss of revenue for home care agencies and hospitals. This article outlines how an agency used telehealth to provide CHF patients quality care and improved outcomes while decreasing the number of skilled home nursing visits and reducing rehospitalization rates to 1.2%.

Durable Medical Equipment↗

PubMed1985

Acute haemodynamic effects of ibopamine in patients with severe congestive heart failure.

Ten patients with congestive heart failure (CHF), in III and IV NYHA Class, were treated orally with a single dose of ibopamine ranging from 1.2-3.3 mg/kg, and were studied using the Swan-Ganz catheter and thermodilution technique. Cardiac index (CI) and stroke volume index (SVI) were increased, and mean pulmonary pressure (PAP), systemic vascular resistances (SVR) were lowered. Ibopamine increased CI (+33%) and SVI (+26%), and decreased PAP (-17%) and SVR (-24%). All changes were statistically significant. The maximum haemodynamic effect occurred 180 min after ibopamine administration. Blood pressure and heart rate were unaffected. Tolerability was good. This study shows that ibopamine when orally administered to human subjects improves cardiac performance and further investigations on its use as a therapeutic agent in the long term treatment of CHF are recommended.

Adult↗

PubMed2005

Clinical factors associated with hyperkalemia in patients with congestive heart failure.

BACKGROUND: Patients with congestive heart failure (CHF) are at risk for hyperkalemia because of coexisting comorbidities and use of multiple medications that impair potassium (K) excretion such as angiotensin converting enzyme (ACE) inhibitors. OBJECTIVE: To identify clinical factors associated with hyperkalemia on initial presentation in patients hospitalized for CHF. DESIGN: A case-control study. SETTING: Two university-affiliated tertiary-care hospitals. SUBJECTS: Using ICD-9 code for CHF, CHF admissions with hyperkalemia on presentation (cases) were identified from a population of 938 non-dialysis-dependent CHF patients. CHF admissions with normokalemia on presentation were used as controls. Hyperkalemia was defined as serum K > or = 5.6 mmol/L, and normokalemia as serum K > or = 3.5 and < or =5.5. METHODS: Data were collected on demographic characteristics, clinical variables, comorbidity and medication use. Factors associated with hyperkalemia on initial presentation were examined. RESULTS: Mean age did not differ between cases [76 years, standard deviation (SD) = 12] and controls (75 years, SD = 12) (P = 0.824). Mean potassium levels for cases and controls were 6.2 mmol/L (range 5.6 to 8.2) and 4.3 mmol/L respectively (P < 0.001). On multivariate analysis, diabetes mellitus [odds ratio (OR) = 2.42, 95% confidence interval (CI) = 1.04-5.59], creatinine clearance <40 mL/min (OR = 8.36, CI = 2.73-25.56), use of spironolactone (OR = 4.18, CI = 1.27-13.79), and use of ACE inhibitors (OR = 2.55, CI = 1.06-6.13) were independently associated with hyperkalemia. CONCLUSIONS: In CHF patients, hyperkalemia on presentation is independently associated with diabetes, creatinine clearance <40 mL/min, use of spironolactone, and use of ACE inhibitors. Recommendations for use of spironolactone and ACE inhibitors in CHF, and the intensity of serum K monitoring need to be clarified to account for patients at higher risk for hyperkalemia.

Aged↗

PubMed2002

Effects of carvedilol on heart rate dynamics in patients with congestive heart failure.

BACKGROUND: Patients with congestive heart failure (CHF) have alterations in the traditional and nonlinear indices of heart rate (HR) dynamics, which have been associated with an increased risk of mortality. This study was designed to test the effects of carvedilol, a nonselective beta-blocker with alpha-1 blocking properties, on HR dynamics in patients with CHF. METHODS: We studied 15 patients with CHF secondary to ischemic or idiopathic cardiomyopathy who met the following inclusion criteria: NYHA functional class II-III, optimal conventional medical therapy, normal sinus rhythm, left ventricular ejection fraction (LVEF) of < 40%, and resting systolic blood pressure greater than 100 mmHg. The 6-minute corridor walk test, estimation of LVEF, and 24-hour Holter recording were performed at baseline and after 12 weeks of therapy with carvedilol. Traditional time and frequency domain measures and short-term fractal scaling exponent of HR dynamics were analyzed. RESULTS: After 12 weeks of therapy with carvedilol, the mean LVEF improved significantly (from 0.27 +/- 0.08 to 0.38 +/- 0.08, P < 0.001). The average HR decreased significantly (from 86 +/- 11 to 70 +/- 8 beats/min, P < 0.001). The mean distance traveled in the 6-minute walk test increased significantly (from 177 +/- 44 to 273 +/- 55 m, P < 0.01). The frequency-domain indices (HF and LF), the time domain indices (rMSSD and PNN5 ), and the short-term fractal scaling exponent increased significantly. The scaling exponent increased particularly among the patients with the lowest initial values (< 1.0), and the change in the fractal scaling exponent correlated with the change in ejection fraction (r = 0.63, P < 0.01). CONCLUSION: Carvedilol improves time and frequency domain indices of HR variability and corrects the altered scaling properties of HR dynamics in patients with CHF. It also improves LVEF and functional capacity. These specific changes in HR behavior caused by carvedilol treatment may reflect the normalization of impaired cardiovascular neural regulation of patients with CHF.

Adrenergic beta-Antagonists↗

PubMed2000

Chronic blockade of brain "ouabain" prevents sympathetic hyper-reactivity and impairment of acute baroreflex resetting in rats with congestive heart failure.

In rats with congestive heart failure (CHF) post myocardial infarction (MI) acute blockade of brain "ouabain" reverses sympathetic hyperactivity and chronic blockade prevents the desensitization of baroreflex function. This study was conducted to determine: i) if chronic blockade of brain "ouabain" maintains normal sympathetic reactivity; and ii) if acute baroreflex resetting (another parameter of baroreflex function) also becomes impaired, and if so, does brain "ouabain" contribute to impairment in acute baroreflex resetting. CHF post MI was induced by acute coronary artery ligation in Wistar rats. Animals were treated with 200 microg x day(-1) i.c.v. or i.v. Fab fragments (which bind brain "ouabain" with high affinity), or treated with 200 microg x day(-1) i.c.v. gamma-globulins (control group). The length of treatment was 0.5-8 weeks or 4-8 weeks post MI. At 8 weeks mean arterial pressure (MAP), central venous pressure (CVP), heart rate (HR), and renal sympathetic nerve activity (RSNA) were recorded in concious rats at rest and in response to: i) air-jet stress, ii) i.c.v. guanabenz (an alpha2-adrenoceptor agonist), and iii) a 30 min i.v. infusion of nitroprusside (NP). Excitatory responses to air stress and inhibitory responses to guanabenz of MAP, HR, and RSNA were significantly enhanced in rats with CHF versus the sham-operated treated group. This enhancement was prevented in the CHF group treated with i.c.v., but not i.v., Fab. Nitroprusside induced a sustained decrease in MAP (approximately 25 mmHg) and a transient decrease in CVP. Heart rate and RSNA increased significantly within 1 min of beginning the infusion. The peak increases as well as the product of changes in MAP-HR and RSNA-HR were significantly smaller in rats with CHF treated with gamma-globulins versus sham rats and versus CHF rats treated with i.c.v. Fab. In sham-operated rats and CHF rats treated with i.c.v. Fab, RSNA and HR began to decrease within 3-4 min of beginning the NP infusion and had returned to baseline by 20 min. In contrast, RSNA and HR remained increased throughout the infusion in the CHF rats treated with gamma-globulins. These data indicate that in rats with CHF acute resetting of the arterial baroreflex in response to a lower BP becomes impaired, and chronic blockade of brain "ouabain" prevents both this change in baroreflex resetting as well as sympathetic hyperactivity.

Animals↗

PubMed2004

Differential alterations of receptor densities of three muscarinic acetylcholine receptor subtypes and current densities of the corresponding K+ channels in canine atria with atrial fibrillation induced by experimental congestive heart failure.

Parasympathetic tone and congestive heart failure (CHF) are two of promoting factors in initiation and perpetuation of atrial fibrillation (AF). Recent studies indicate co-existence of multiple muscarinic acetylcholine receptor subtypes (mAChRs) that mediate several distinct K+ currents in the heart; inward rectifier K+ current IKACh by the M2, and two delayed rectifier K+ currents IKM3 and IK4AP by the M3 and M4 receptors, respectively. We studied the alterations of atrial mAChRs and their coupled K+ channels in the setting of AF in dogs with ventricular tachypacing-induced CHF. Whole-patch-clamp recordings showed that the current densities of IKACh (induced by 1 mM acetylcholine) and IK4AP (induced by 1 mM 4-aminopyridine) were ñ45% and ñ55% lower, respectively, while that of IKM3 (induced by 10 mM choline) was ñ75% higher, at a plateau voltage of 0 mV in atrial myocytes from CHF than those from healthy hearts. In healthy hearts, IKACh comprised >60%, and IKM3 and IK4AP <30%, of the total outward K+ currents mediated by mAChRs at depolarized potentials (between -20 mV and +50 mV). In AF atria of CHF dogs, however, the contribution of IKM3 increased to approximately 50%, exceeding those of IKACh or IK4AP. Western blot analyses with atrial membrane protein samples indicated that receptor densities of the M2 and M4 subtypes decreased by approximately 33% and approximately 22%, respectively, whereas that of the M3 subtype increased by approximately 2.3 folds, in parallel to the alterations of the corresponding K+ currents. We conclude that differential alterations of mAChR subtypes underlie differential alterations of their coupled K+ channels in AF atria and these differential alterations may contribute to atrial remodeling in AF induced in the setting of CHF.

Animals↗

PubMed1989

Home intermittent amrinone infusions in terminal congestive heart failure.

The prevalence of congestive heart failure (CHF) and its progressive degenerative course continue to generate pressure for alternative, more effective means of treatment. A confluence of factors, including the number of Americans with CHF, the spiraling costs of hospital care, and increasing interest in cost-effective home care, contribute to the current efforts to develop an effective, nontoxic therapy that effectively increases myocardial contractility and output and can be administered within the confines of the home. Given that preliminary clinical trials in the hospital setting with amrinone have produced positive results, the transition of this therapy to the home, when administered intermittently via central venous catheter and infusion pump, was undertaken. In order to prolong and increase quality of life in terminal CHF patients, intermittent amrinone infusions were provided at home to four patients as part of our pilot program. All four patients met the criteria for New York Heart Association (NYHA) functional class IV heart failure, and none had responded to conventional therapy suitable for outpatient maintenance. The patients also shared strong family support and an intense desire to improve the quality of remaining life. All four patients and designated family members were trained in the specifics of aseptic technique, medication dose preparation, central venous catheter care, and operation of an infusion pump. An ambulatory pump was used in three of the four patients. Subsequent to the initiation of intermittent home amrinone infusions, all four patients had greater tolerance to limited exercise and/or ambulation secondary to increased cardiac output and diuresis. Patients survived 8, 10, 47, and 56 weeks.(ABSTRACT TRUNCATED AT 250 WORDS)

Aged↗

PubMed1993

Cardiac index vs oxygen-derived parameters for rational use of dobutamine in patients with congestive heart failure.

In patients with congestive heart failure (CHF), catecholaminergic agents may exert thermogenic effects that limit their beneficial effects in terms of global tissue oxygenation. Oxygen extraction ratio (O2ER) or mixed venous blood saturation (SvO2) might take into account better than cardiac index (CI) the resultant effect of such agents on peripheral oxygenation. We tested this hypothesis in a series of 20 patients with severe CHF and normal blood lactate levels undergoing pulmonary artery catheterization and receiving incremental doses of dobutamine: 0 (Do), 5 (D5), 10 (D10), and 15 micrograms/kg/min (D15). A significant dose-effect relationship (p < 0.01) was found between dose of dobutamine and CI (CI = 0.06 dose + 1.82). By contrast, no dose-effect relationship was observed between dobutamine dose and either O2ER or SvO2. Indeed, a biphasic profile was observed for O2ER and SvO2. From D0 to D10, O2ER decreased (from 45 +/- 6 to 35 +/- 7 percent) and SvO2 increased (from 52 +/- 7 to 62 +/- 7 percent). From D10 to D15, no further change was observed for both parameters. This latter finding was related to a significant increase in VO2 at D15 (p < 0.01). In these normolactatemic patients with unchanged VO2 from D0 to D10 while DO2 linearly increased (from D0 to D15), the increase in VO2 at D15 was probably due to an increase in oxygen demand induced by the drug. Our results suggest that dobutamine at a dose of 15 micrograms/kg/min can induce an increase in O2 demand that might offset the improvement in CI. Thus, in patients with CHF, oxygen-derived parameters such as O2ER and SvO2 should be more appropriate than CI to assess the efficacy of dobutamine.

Adult↗

PubMed2003

Intravenous vasodilator therapy in congestive heart failure.

The prevalence of congestive heart failure (CHF) is increasing in the US and worldwide, partly because patients are living longer. Treatment of CHF is mostly on an outpatient basis, but inpatient care is required for decompensated CHF, acute CHF or poor response to outpatient treatment. Control of symptoms is usually achieved by diuresis. Intravenous (IV) vasodilators are an important adjunct to the inpatient treatment of CHF. They work mainly by reducing the afterload on the myocardium although preload reduction also occurs. After clinical stabilisation, the goal is to switch to a maintenance oral regimen to be continued as outpatient therapy. The range of IV vasodilators available for inpatient treatment of CHF includes nitrates, phosphodiesterase inhibitors, dobutamine, morphine, ACE inhibitors, B-type natriuretic peptides and endothelin receptor antagonists. As each agent may have a different mechanism or site of action, each agent may affect preload, contractility or afterload to a different extent and it may be desirable to choose one over the other in a particular clinical setting. Examples of standard therapy include dobutamine, milrinone and nitroglycerin. Nesiritide, a B-type natriuretic peptide, is a newer vasodilator and US FDA approved for use in acute CHF. However, most studies with this agent have been in small numbers of patients with anecdotal findings. Larger studies are warranted to pinpoint the efficacy and adverse effects of this agent. It is primarily used to reduce the acuity of decompensated CHF on admission to hospital.Endothelin receptor antagonists show promise in the management of acute CHF, but continue to be investigational. Long-term data on their efficacy and safety are limited. None of the endothelin receptor antagonists are FDA approved for use in patients with CHF.

Dobutamine↗

PubMed2000

[Role of surgery in the treatment of severe congestive heart failure].

Patients with severe congestive heart failure which is not reversible by therapy and caused by mechanical abnormalities that are not surgically correctable, generally constitute desperate cases in which surgical intervention is only palliative. Currently, only transplantation can be considered an adequate mid-term therapy, while cardiomyoplasty and ventricular reduction (Batista) have not evolved as viable alternatives. The former has not yielded satisfactory results and the experience with the latter is still too short, although the short term results also appear discouraging. The shortage of available organs for the number of patients on the waiting list and the rejection and infection phenomena, which remain the main difficulties with transplantation, may be overcome in the not too distant future. Finally, the artificial heart will almost certainly be an alternative, but it may, eventually, be overthrown by xenotransplantation.

Cardiomyoplasty↗

PubMed2001

Reducing readmissions for congestive heart failure.

Hospital admission for congestive heart failure is extremely common and quite expensive, although it is frequently preventable. New drugs and therapies have been reported to reduce admissions, decrease morbidity and mortality, and improve the quality of life for these patients. Patients with an ejection fraction less than 40 percent (decreased systolic function) should be treated with medication to improve symptoms and prevent progression of heart failure. Angiotensin-converting enzyme (ACE) inhibitors are a mainstay of treatment in patients who can tolerate them; in patients who cannot take these drugs, angiotensin II receptor blocking agents offer an alternative. Patients with New York Heart Association class II or III heart failure should also receive a beta blocker (metoprolol, carvedilol or bisoprolol). Recent research has shown that treatment with spironolactone improves mortality and hospital readmission rates. An exercise program should also be recommended for all patients with heart failure unless their condition is unstable.

Adrenergic beta-Antagonists↗

PubMed2001

Changing trends in mortality and admissions to hospital for elderly patients with congestive heart failure in Montreal.

BACKGROUND: Congestive heart failure (CHF) is a common disease requiring admission to hospital among elderly people and is associated with a high mortality rate. The objective of this study was to examine trends in CHF mortality and admissions to hospital in Montreal between 1990 and 1997 for individuals aged 65 years or more. METHODS: We obtained information about deaths from the Quebec Death Certificate Registry database and information about admissions to hospital from the Quebec Med-Echo database. Patients with a primary diagnosis that was classified as ICD-9 code 428 were considered cases of CHF. RESULTS: Although age-adjusted rates of mortality from CHF did not change significantly between 1990 and 1997, the annual rate of admission to hospital for CHF increased from 92 per 10,000 population in 1990/91 to 124 per 10,000 population in 1997/98 (p < 0.01). Deaths due to CHF, expressed as a proportion of all cardiovascular deaths, increased among women from 5.6% in 1990 to 6.2% in 1997 (p = 0.01). The rate of readmission for all causes following a first admission for CHF during that year rose over the study period from 16.6% to 22.0% within one month (p < 0.001) and from 46.7% to 49.4% within 6 months (p = 0.03). Conversely, mean annual length of stay per admission decreased from 16.4 days in 1990/91 to 12.2 days in 1997/98. INTERPRETATION: The increase in rates of admission to hospital for CHF and the stable rates of CHF mortality suggest that the management of CHF and its antecedents has improved in recent years.

Aged↗

PubMed2001

New therapeutic choices in the management of acute congestive heart failure.

Patients with acute congestive heart failure generally present with profound fluid retention states and dyspnea due to pulmonary edema. If the condition is not aggressively and appropriately treated, irreversible cardiac decompensation may ensue, leading to cardiogenic shock, multiorgan failure, and death. Intravenous inotropic, vasopressor, and vasodilator therapies have proved effective in initial stabilization of acute heart failure decompensation, but these agents, particularly the traditionally used ones, are generally limited by side effects that can be egregious and include substantive ventricular arrhythmias. Dobutamine has largely replaced agents with rather profound toxicity, such as isoproterenol and epinephrine. The phosphodiesterase-inhibiting agent milrinone, having both vasodilator and inotropic properties, can produce tachycardia and significant ventricular arrhythmias, but has proven quite useful for seriously ill patients. Clinical trials of levosimendan have found a positive inotropic response when the drug is given parenterally; vasodilating properties are also evident. Clinical trials are under way to evaluate the potential benefits of endothelin receptor antagonists when given intravenously. Intravenous administration of nesiritide, a recombinant human B-type natriuretic peptide, has been shown to produce favorable hemodynamic effects, including balanced vasodilation associated with a rapid improvement in clinical symptoms.

Acute Disease↗

PubMed2003

Evidence for the survival benefit of neurohormonal antagonists in the management of geriatric congestive heart failure.

The prevalence of congestive heart failure (CHF) doubles with each decade after the fourth decade. CHF is associated with significant mortality and morbidity. Renin-angiotensin-aldosterone and sympathetic nervous systems play a pivotal role in the progression and deterioration of CHF. Multiple, double-blinded, randomized and placebo-controlled trials have shown significant survival benefit and improved quality of life with the use of neurohormonal antagonists, viz. angiotensin converting enzyme (ACE) inhibitors, angiotensin II receptor type 1 blockers, beta-blockers and spironolactone in the management of CHF. While important for the symptom control, diuretics and digoxin are not associated with any decrease in mortality in patients with CHF. Despite overwhelming evidence of decreased mortality and morbidity, neurohormonal antagonists remain under-utilized in the management of CHF. This article will review the current evidence for the survival benefit with the use of neurohormonal antagonists in CHF.

Age Factors↗