One of the most important comorbidities in heart failure is renal dysfunction. Diminished estimated glomerular filtration rate is a potent predictor of cardiovascular mortality and complications. On the other hand, worsening heart failure or acute decompensated heart failure can accelerate worsening of renal function--the so-called cardiorenal syndrome. Risk factors include hypertension, diabetes, elderly age, and prior history of heart or renal failure. The pathophysiology of the cardiorenal syndrome involves intrarenal hemodynamics, transrenal perfusion pressure and systemic neurohormonal factors. Clinical management of the patient with cardiorenal syndrome includes the challenge of diuretic resistance, which may involve correcting the underlying cause, combination diuretics or diuretic infusions. The key to improved outcome is the optimization of proven heart failure therapies. The use of vasodilator therapy is the current mainstay of treatment. Nesiritide, or recombinant B-type natriuretic peptide, has courted controversy regarding its role in cardiorenal syndrome. However, data are emerging that low doses appear to be renal-protective. Other more recent strategies include ultrafiltration, vasopressin antagonists and adenosine antagonists. All of these newer modalities promise more rapid volume removal, but their ultimate impact on survival or preservation of renal function is unknown at the present time. Because of the complex nature of these patients, and the compromised outcome, it is important that cardiologists, nephrologists and internists all work together toward the common goal of protecting the patient with cardiorenal syndrome, and use the best available evidence for management.
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Sex differences (or a 'sex gap') exist in the rates of cardiac revascularization. It was evaluated whether physician preference contributes to this difference.
To obtain information on how cardiac specialists manage male and female patients being evaluated for coronary artery disease.
A computer-based patient simulation program was developed. Six sex-matched clinical vignettes (three pairs) with uninterpreted coronary angiograms were shown to specialists, who were blinded to the purpose of the study. The sex-matched scenarios were balanced with respect to symptoms, comorbidities and coronary anatomy. Physicians were surveyed on management and rationale.
Fifty physicians were surveyed, consisting mainly of cardiologists from tertiary cardiac centres in Ontario. Among the three sexmatched pairs, the frequencies at which percutaneous coronary intervention (including drug-eluting stents), bypass surgery and medical therapy were chosen did not differ across sexes. The means for men and women, respectively, were 47% and 50% for percutaneous coronary intervention, 32% and 26% for bypass surgery, and 21% and 24% for medical treatment.
In the present pilot study, cardiac specialists chose similar rates of medical, interventional and surgical procedures independent of a patient's sex. Although large registry trials show that sex differences in management exist, the present data suggest that cardiac specialist preference is less likely to be a factor if coronary angiography was performed. Further research is required to explore the causes of sex discrepancies in cardiac care.
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