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PubMed1987

Cardiovascular response to orthostatic tilt in patients with severe congestive heart failure.

Baroreflex mediated haemodynamic responses and aortic pulsatile stretch were studied in patients with congestive heart failure due to ischaemia. Seven patients with severe congestive heart failure (baseline angiographic ejection fraction 21(3)% (mean(SEM); left ventricular end diastolic volume and pressure 351(43) ml and 22(3) mmHg respectively) were compared with seven control subjects whose angiographic ejection fraction was 74(3)%. Passive 45 degrees upright tilt was used to unload baroreceptors. Aortic pulsatile stretch (pulsatile distension as percentage of diastolic diameter) was calculated from echocardiographic measurements of aortic diameters. Upright tilt caused a significant decrease in cardiac filling pressures in patients with congestive heart failure, as in control subjects. During tilt control subjects had substantially increased systemic vascular resistance and heart rate and decreased stroke volume, but arterial pressure, cardiac index, and aortic pulsatile stretch were maintained constant. Patients with congestive heart failure developed peripheral vasodilatation, had no increase in heart rate, and failed to maintain arterial mean and systolic pressures in the tilted position. They had, however, maintained a constant pulse pressure and increased cardiac index, stroke volume, and aortic pulsatile stretch. The response to upright tilt in patients with congestive heart failure may be explained by faulty sympathetic reflexes, causing vasodilatation and hypotension rather than vasoconstriction, and a rise in stroke volume due to the decrease in afterload.

Aorta↗

PubMed1996

Diastolic plateau wave of pulmonary artery pressure in severe congestive heart failure.

We describe 3 cases of severe congestive heart failure. The patients exhibited a marked decrease in transmitral flow velocity during atrial contraction and an abnormal diastolic plateau wave of pulmonary artery pressure (PAP). The first patient was a 60-year-old man with acute myocardial infarction and acute renal failure in whom pulmonary capillary wedge pressure (PCWP) was raised to 20 mmHg. Pulsed Doppler echocardiography revealed a marked decrease in transmitral flow velocity during atrial contraction, and the PAP waveform showed a mid to late diastolic plateau wave. Treatment for congestive heart failure reduced PCWP to 10 mmHg and the PAP waveform returned to normal. Doppler examination revealed the normal transmitral flow velocity pattern. The second patient was a 37-year-old woman with subarachnoid hemorrhage and the third patient a 74-year-old man with acute myocardial infarction. In these patients, the PAP waveform also showed a diastolic plateau wave, which was abolished by treatment. We believe that the diastolic plateau wave of PAP indicates left ventricular diastolic dysfunction and marked elevation of left ventricular filling pressure.

Adult↗

PubMed1979

Contributions of hemodynamic monitoring to the treatment of chronic congestive heart failure.

Optimal therapy for congestive cardiac failure requires identification of correctable factors that aggravate it as well as an understanding of its etiology. Increased sympathetic nervous system activity, reduced renal blood flow, and cardiac hypertrophy and dilation are the main compensatory processes that occur in response to cardiac failure. Although they may be of initial benefit in supporting a reduced stroke volume, they may ultimately prove self-defeating. New drugs for the treatment of severe congestive heart failure include dopamine, which has a selective nonadrenergic dilator effect on the renal vascular bed, and dobutamine, which has potent inotropic effects, lowers the left ventricular filling pressure and does not increase the heart rate or the systemic vascular resistance. By reducing both the resistance to left ventricular ejection and the venous return to the right heart, vasodilators result in improved peripheral perfusion and reduced pulmonary congestion. Optimal therapy for refractory cardiac failure can be rationally determined by characterizing the hemodynamic profile through measurement of the mean arterial pressure, the left ventricular filling pressure, the cardiac output and the systemic vascular resistance. The specific therapy can then be effectively and safely delivered by a careful analysis of the dose-response relation as identified by hemodynamic monitoring.

Chronic Disease↗

PubMed1991

Current role of digitalis therapy in patients with congestive heart failure.

Digitalis has been used in the treatment of chronic congestive heart failure for 215 years. In this article, numerous clinical studies and trials that have evaluated the efficacy of digitalis in the treatment of patients with congestive heart failure are reviewed. The data indicate that digitalis is a valuable therapeutic agent for relieving symptoms and improving exercise performance and left ventricular function in patients with congestive heart failure. Comparison of the various advantages and disadvantages of digitalis with alternative therapies in patients with congestive heart failure shows an important continuing role for digitalis therapy.

Clinical Trials as Topic↗

PubMed1986

Haemodynamic, radionuclide ventriculography and ergometric evaluation of captopril treatment in congestive heart failure.

Eight patients with NYHA Class II congestive heart failure were studied before and after captopril with right heart catheterization, cycloergometric stress tests and radionuclide 99Tc cineventriculography. Acute administration of captopril increased stroke volume and cardiac index and reduced left ventricular filling pressure. Similar changes though less marked were seen after 30 days of captopril therapy. Functional aerobic capacity and left ventricular performance improved over 15 and 30 days of captopril respectively. We therefore suggest that captopril can be effective also in patients with moderate congestive heart failure.

Adolescent↗

PubMedDate not supplied

Management of atrial fibrillation in patients with congestive heart failure.

An increase in the prevalence of both atrial fibrillation and congestive heart failure is occurring in part because of the demographic shift toward an aging population. These two clinical entities often coexist in the same patient, resulting in the worsening of symptoms and prognosis, rendering their management even more challenging. A large clinical trial is currently examining whether a rhythm-control strategy is superior to a rate-control strategy in patients with congestive heart failure. New nonpharmacologic therapies such as pulmonary vein isolation are undergoing clinical investigation and may also alter the management of these patients. At present, therapy for atrial fibrillation in patients with congestive heart failure should aim first at controlling heart rate to provide symptomatic relief; then sinus rhythm should be restored if symptoms persist or if congestive heart failure worsens. For a more definitive approach in managing these patients, the authors await further clinical trial data.

Aged↗

PubMedDate not supplied

Outcomes for patients with congestive heart failure in a nursing case management model.

Congestive heart failure is a leading cause of hospital admissions, costing an estimated $7 billion in 1990. Hospital-based nursing case management has been used to reduce costs of care while maintaining quality of care. This study describes the outcomes for 50 patients with congestive heart failure in a hospital-based nursing care management model, providing general outcomes, physiologic status, physical functioning, health knowledge, and family caregiver status. The number of medications was the only predictor of length of stay using regression analysis.

Activities of Daily Living↗

PubMed1998

A new casemix adjustment index for hospital mortality among patients with congestive heart failure.

OBJECTIVES: Comparative analysis of hospital outcomes requires reliable adjustment for casemix. Although congestive heart failure is one of the most common indications for hospitalization, congestive heart failure casemix adjustment has not been widely studied. The purposes of this study were (1) to describe and validate a new congestive heart failure-specific casemix adjustment index to predict in-hospital mortality and (2) to compare its performance to the Charlson comorbidity index. METHODS: Data from all 4,608 admissions to the Massachusetts General Hospital from January 1990 to July 1996 with a principal ICD-9-CM discharge diagnosis of congestive heart failure were evaluated. Massachusetts General Hospital patients were randomly divided in a derivation and a validation set. By logistic regression, odds ratios for in-hospital death were computed and weights were assigned to construct a new predictive index in the derivation set. The performance of the index was tested in an internal Massachusetts General Hospital validation set and in a non-Massachusetts General Hospital external validation set incorporating data from all 1995 New York state hospital discharges with a primary discharge diagnosis of congestive heart failure. RESULTS: Overall in-hospital mortality was 6.4%. Based on the new index, patients were assigned to six categories with incrementally increasing hospital mortality rates ranging from 0.5% to 31%. By logistic regression, "c" statistics of the congestive heart failure-specific index (0.83 and 0.78, derivation and validation set) were significantly superior to the Charlson index (0.66). Similar incrementally increasing hospital mortality rates were observed in the New York database with the congestive heart failure-specific index ("c" statistics 0.75). CONCLUSION: In an administrative database, this congestive heart failure-specific index may be a more adequate casemix adjustment tool to predict hospital mortality in patients hospitalized for congestive heart failure.

Aged↗

PubMed2003

Digoxin increases mortality among women with congestive heart failure.

Digoxin increases mortality in women with congestive heart failure, compared with men; however, the clinical significance of this is unknown since gender is a nonmodifiable risk factor. More importantly, there is a suggestion of harm when looking at women treated with digoxin versus placebo. Since there are other therapies with definite benefit in congestive heart failure (angiotensin-converting enzyme inhibitors, beta-blockers, spironolactone), it is prudent to reconsider the use of digoxin in women with ejection fractions less than 45%.

Comment↗

PubMed1975

Dosage titration with furosemide in congestive heart failure patients.

Clinical status and diuretic requirements of a group of congestive heart failure patients were re-evaluated. A group of 115 congestive heart failure patients were hospitalized, given a comprehensive medical examination and treated with placebo for four weeks. Thirteen patients did not exhibit signs and symptoms of congestive heart failure during this phase. The remaining 102 patients were treated with 40 mg furosemide per day for a second 4-week period. Fifty-three required 80-120 mg furosemide per day and 49 were successfully controlled at 40 mg per day. Ten patients dropped out voluntarily and 39 were controlled for an additional four weeks at a dose of 20 mg bid furosemide. In the final phase, dosage was lowered to 20 mg per day and 24 of the 39 patients, (62%), were successfully controlled for four weeks, while 14, (36%), were controlled for eight weeks. Results of this study suggest that a number of congestive heart failure patients can be controlled with relatively low doses of furosemide and that there is a need for periodic re-evaluation of the clinical status and diuretic requirements of patients on maintenance therapy.

Adult↗

PubMed2005

Digoxin may reduce the mortality rates in patients with congestive heart failure.

Digoxin has been used to treat congestive heart failure (CHF) for more than two centuries. It's clinical efficacy, however, has been under question in recent years because recent clinical trials showed that digoxin therapy in CHF patients was associated with no beneficial effects in mortality, but only a modest reduction in clinical symptoms and the frequency of heart failure related hospitalisation. Digoxin's effect on mortality seems closely related to its serum concentrations; high serum concentrations (e.g. >or=1.2 ng/ml) have been found to increase the risk of all-cause mortality in heart failure patients. Digoxin-associated risk in mortality may be due to an increases in myocardial oxygen consumption and arrhythmogenesis at higher serum concentrations. We hypothesized that the serum concentration of digoxin is a major determinant factor of its efficacy on mortality rates in patients with congestive heart failure. The maintenance of digoxin's serum concentration at the lower end of the reference range, i.e., between 0.5 and 0.8 ng/ml, may reduce mortality rates as well as improve clinical symptoms.

Cardiotonic Agents↗

PubMed1981

Effect of captopril on renal function in patients with congestive heart failure.

Angiotensin converting enzyme inhibitors can improve haemodynamics in patients with congestive heart failure and may enhance sodium excretion in hypertensive patients. In a metabolic unit we assessed the effects of one of these agents on renal function in nine patients with stable New York Heart Association functional class 3 or 4 congestive heart failure. Single blinded, the patients received placebo for three days, 25 to 100 mg of captopril three times a day for three days, and three more days of placebo. Mean blood pressure decreased during captopril, with little change in heart rate or respiration. Serum urea was slightly higher during captopril administration. The mean change in creatinine clearance during captopril was insignificant, but it decreased more than 25% in three of nine patients. Decreases in creatinine clearance correlated with lower blood pressure during captopril and were most obvious in patients with high baseline plasma renin activity. Urine output and both sodium and potassium excretion decreased during captopril. Thus captopril failed to improve natriuresis in patients with congestive heart failure and close monitoring of kidney function is necessary when using this agent in patients with congestive heart failure, particularly when blood pressure falls to lower levels.

Aged↗

PubMed1977

Profound spontaneous hypoglycaemia in congestive heart failure.

Eleven cases of spontaneous hypoglycaemia in congestive heart failure in adults are reported. There were 5 males and 6 females, aged from 15 to 65 years (mean, 44 years). Blood sugar ranged from 2 to 42 mg/100 ml (mean 21 mg/100 ml). Six patients were in coma on admittance, 1 was confused, and 4 were conscious. The underlying condition was rheumatic valvular heart disease (3), chronic obstructive lung disease (4), cornonary heart disease (3) and cardiomyopathy (1). Five of the 11 patients died. The mechanism of hypoglycaemia is discussed and thought to be a combination of factors such as liver dysfunction, low calorie intake, malabsorption, and increased glusose utilization by ischaemic tissues, including the heart. It is recommended that in patients with congestive heart failure presenting with coma or confusion, blood sugar should be checked for possible hypoglycaemia.

Adolescent↗

PubMedDate not supplied

Congestive heart failure and cognitive impairment in the elderly.

Congestive heart failure (CHF) represents the most frequent cause of death and disability in the elderly. The prevalence of impairment of cognitive abilities is very high in aging and several clinical studies have demonstrated high association between cardiovascular diseases (in particular CHF) and cognitive deterioration. However, little attention has been paid to the decline of cognitive functioning during congestive heart failure in elderly patients. In this paper an overview of studies investigating this association is offered, suggesting that hemodynamic alterations due to heart failure and cognitive deteriorations are very frequently associated in aging, increasing morbidity and mortality risks. Moreover, preliminary results of a prospective study on hospitalized elderly patients with heart disease are reported (CHF Italian Study). These data show that some psychosocial variables (illiteracy, depression, and particularly cognitive deterioration) determine a significant increase of the risk to develop heart failure. This paper confirms that a multidimensional approach is necessary to better characterize and treat elderly patients, in particular those with CHF. More attention should be paid to encourage mild physical activity, to provide emotional support to patients and also to assess their general cognitive abilities. Studies on large populations of patients with heart disease have to be designed to investigate psychosocial and cognitive status in these patients.

Journal Article↗

PubMed1989

Prognostic evaluation of congestive heart failure in patients with Duchenne muscular dystrophy--retrospective study using non-invasive cardiac function tests.

The relation between heart function and the prognosis of patients with Duchenne muscular dystrophy (DMD) was analyzed in 27 non-survivors and 40 survivors by fractional shortening (FS) of the left ventricle from M-mode echocardiogram, and by the PEP/ET ratio from the systolic time interval. The patients were divided into 5 groups; (1) patients who died of congestive heart failure (group 1), (2) those who died of congestive heart failure and respiratory failure (group 2), (3) those who died of respiratory failure (group 3), (4) those who died suddenly of undefined etiology (group 4), and (5) survivors (group 5). Data from non-invasive cardiac function tests were analyzed retrospectively for 2 years and compared at 2 years, 1 year and about 3 months before their deaths in cases of group 1, 2, 3 and 4, and the data obtained at the same period were also compared with those of survivors (group 5). The age at death in group 1 (17.3 +/- 4.9 years) was significantly younger than that in group 2 (25.3 +/- 4.2 years), however, it did not statistically differ from group 3 (19.8 +/- 3.3 years old). The values of FS in group 1 were significantly lower than those in group 3, 4 and 5 at three examinations, whereas no difference in PEP/ET was observed among them. Cardiothoracic ratio (CTR) on chest X-ray in group 1 was not significantly different from other groups in each period, but the left ventricle dilated rapidly in the terminal stage of congestive heart failure which could be more precisely detected by the M-mode echocardiogram. These results indicate that in DMD, early development of congestive heart failure was associated with a poor prognosis. FS was a most sensitive non-invasive tool in predicting the prognosis. A significant reduction in FS was detectable 2 years before death. Progression in abnormality of left ventricular dimension as well as in FS may be another useful index for evaluating the prognosis of patients dying from congestive heart failure.

Adolescent↗

PubMed1996

A cardiologist's perspective on evolving concepts in the management of congestive heart failure.

The conceptual framework for treatment of congestive heart failure has changed dramatically in the past 30 years. The 1950s and 1960s were characterized by manipulation of the left ventricular function curve by digitalis and diuretics. The 1970s focused on relief of symptoms by afterload reduction with vasodilators. Then stimulation of cardiac output with inotropes was shown to relieve symptoms, but patients died sooner. Now the focus is on the neurohumeral milieu and methods to counteract excess renin-angiotensin and sympathetic nervous system stimulation. Angiotensin-converting enzyme inhibitors are the drugs of choice because they also improve survival, but beta-blockers are becoming popular. The effect of molecular cardiology on practice guidelines for congestive heart failure is yet to be seen.

Clinical Trials as Topic↗

PubMed1994

Heart rate variability and its relation to ventricular arrhythmias in congestive heart failure.

BACKGROUND: It has been shown that heart rate variability is decreased in patients with congestive heart failure and that depressed heart rate variability is associated with a propensity to ventricular arrhythmias. Little is known, however, about heart rate variability in patients with both congestive heart failure and ventricular arrhythmias. METHODS: Spectral heart rate variability was analysed from 24 hour ambulatory electrocardiograms in 15 controls, 15 patients with non-sustained ventricular tachycardia associated with clinically normal hearts (NHVT group), and 40 patients with congestive heart failure (CHF group) secondary to either ischaemic heart disease (n = 15) or idiopathic dilated cardiomyopathy (n = 25). Of the 40 patients with congestive heart failure 15 had no appreciable ventricular arrhythmias (ventricular extrasystoles < 10 beats/h and no salvos) and formed the CHF-VA- group. Another 15 patients with congestive heart failure and non-sustained ventricular tachycardia formed the CHF-NSVT group. RESULTS: Heart rate variability was significantly lower in the CHF group than in controls (mean (SD) total frequency 23 (12) v 43 (13) ms; low frequency 12 (8) v 28 (9) ms; high frequency 8 (5) v 14 (7) ms; p < 0.001). The differences in heart rate variability between controls and the NHVT group, between ischaemic heart disease and dilated cardiomyopathy, and between the CHF-VA- and CHF-NSVT groups were not significant. In the CHF group heart rate variability was significantly related to left ventricular ejection fraction but not associated with ventricular arrhythmias. The frequency of ventricular extrasystoles was significantly related to the high frequency component of heart rate variability (r = 0.54, p < 0.05) in the NHVT group. Stepwise multiple regression analysis showed that in the CHF group, heart rate variability was predominantly related to left ventricular ejection fraction (p < 0.05). There was no significant difference in heart rate variability between survivors (n = 34) and those who died suddenly (n = 6) at one year of follow up in the CHF group. CONCLUSION: In patients with congestive heart failure, heart rate variability is significantly decreased. The depressed heart rate variability is principally related to the degree of left ventricular impairment and is independent of aetiology and the presence of ventricular arrhythmias. The data suggest that analysis of heart rate variability does not help the identification of patients with congestive heart failure at increased risk of sudden death.

Adult↗

PubMed1992

Prevalence and mortality rate of congestive heart failure in the United States.

OBJECTIVES: The study was designed to determine the prevalence and mortality rate of congestive heart failure in noninstitutionalized men and women in the U.S. BACKGROUND: Congestive heart failure is a serious condition with significant morbidity and mortality. Earlier epidemiologic descriptions of congestive heart failure were constructed from small surveys, limited data, hospital records or death certificates. No nationally representative data from noninstitutionalized persons have been examined. METHODS: Data collected from the National Health and Nutrition Examination Survey (NHANES-I, 1971 to 1975) were used to determine the prevalence of heart failure on the basis of both self-reporting and a clinical definition. Mortality data were derived from the NHANES-I Epidemiologic Follow-up Study (1982 to 1986). RESULTS: The prevalence of self-reported congestive heart failure approximates 1.1% of the noninstitutionalized U.S. adult population; the prevalence of congestive heart failure based on clinical criteria is 2%. These estimates suggest that between 1 and 2 million adults are affected. Mortality at 10 and 15 years for those persons with congestive heart failure increases in graded fashion with advancing age, with men more likely to die than women. In the group greater than or equal to 55 years old, the 15-year total mortality rate was 39.1% for women and 71.8% for men. CONCLUSIONS: Congestive heart failure is a common problem in the U.S., with significant prevalence and mortality, both of which increase with advancing age. As the population of the U.S. becomes older, the health care impact of congestive heart failure will probably grow.

Adult↗