Acute administration of a single dose of valsartan improves left ventricular functions: a pilot study to assess the role of tissue velocity echocardiography in patients with systemic arterial hypertension in the TVE-valsartan study I.
BACKGROUND: The advent of colour-coded tissue velocity echocardiography (TVE) has now made it possible to quantify left ventricular (LV) functions in patients with systemic arterial hypertension (HTN). Hypothesis In this project, we have studied the cardiac effects of a single dose of orally administered valsartan in patients with known HTN. METHODS: Fifty-five patients with HTN with a mean age of 56 +/- 10 years were given an early morning dose of 80 mg valsartan withholding regular antihypertensive medications on the day of investigation. TVE images, acquired on VIVID systems were digitized for postprocessing of longitudinal and radial peak systolic velocities, strain rate, and systolic and diastolic time intervals before (pre) and 5 h after (post) administration of the drug. RESULTS: Blood pressure (mmHg) pre and post, respectively, were 147 +/- 15 versus 137 +/- 14 systolic and 90 +/- 7 versus 86 +/- 7 diastolic (all P
The acute dose-related effects of small to moderate doses of ethanol on right ventricular functioning were studied on 18 anesthetized, artificially ventilated dogs in 39 sessions. Diluted ethanol (from 25-37.5%) was infused during 40 minutes, yielding total doses of 1.0 g/kg (n = 15), and 1.5 g/kg (n = 12) with corresponding venous blood ethanol peak concentrations of 1.38 +/- 0.25 and 2.41 +/- 0.31 mg/ml, respectively. Heart rate increased up to 16% in groups receiving ethanol. In the control group receiving the equivalent volume of saline (n = 12) heart rate decreased 14%. Pulmonary arterial systolic pressure increased from 24 +/- 3 to 27 +/- 3 mmHg and diastolic pressure from 11 +/- 2 to 14 +/- 4 mmHg (p less than 0.05) when the ethanol dose was 1.0 g/kg. The pulmonary arterial resistance increased from 620 +/- 135 to 805 +/- 185 dyn.s.cm-5 (p less than 0.01). The peak dP/dt decreased maximally by 20% with increasing ethanol doses. Stroke volume decreased maximally by 14% but due to the increase in heart rate, cardiac output even increased. The changes in end-diastolic volume and pressure were not significant. Hence, the ethanol increased heart rate and afterload of the right ventricle but depressed the myocardium.
The short- and long-term hemodynamic effects of encainide, a new class IC antiarrhythmic agent, were studied in 25 patients (mean age 61 +/- 11) with complex symptomatic ventricular arrhythmia and left ventricular dysfunction. Ninety-two percent had previous myocardial infarction and 8% had dilated cardiomyopathy. Seventy-five percent had congestive heart failure, class III or IV, according to the New York Heart Association. All patients underwent a nuclear ventriculogram performed at least 3 days after discontinuing previous antiarrhythmic drugs. Nuclear ventriculograms were repeated 1 to 6 weeks later while the patients were receiving therapeutic doses of encainide ranging from 75 to 300 [corrected] mg/day. Nuclear ventriculograms were also repeated after 6 months or 1 year of encainide therapy in 16 of these patients. Encainide did not have significant effects on heart rate, blood pressure, left ventricular ejection fraction, systolic or end-diastolic volumes. None of the patients showed a worsening of congestive heart failure during encainide therapy. These results compare favorably with those of other class I antiarrhythmic agents. A review of published reports on the hemodynamic effects of intravenous encainide shows it to have a mild but statistically significant dose-related depressant effect on cardiac function. This effect, however, appears to be no different from that of other newer class I agents.
The effects of six week, high-dose anabolic steroid treatment (methandienone, 1.5 mg/kg/day) on the changes in left ventricular function induced in dogs by endurance training were studied by a catheterization technique under anaesthesia. Pacing, isoproterenol and dextran infusions were used as loading tests (respectively). Dogs were randomized into an exercise group (EG, n = 7) and an exercise-steroid group (ESG, n = 7), the latter receiving anabolic steroids as well as participating in the training program. In a standardized submaximal exercise test, the heart rate of unanesthetized dogs was lower both in the EG (p less than 0.001) and in the ESG (p less than 0.01) after the training period than before it. In the EG the resting systemic vascular resistance (SVR) before haemodynamic interventions was lower (p less than 0.05) and left ventricular stroke work (SW) was higher (p less than 0.05) after the training period than before. In the ESG, left ventricular ejection fraction (EF) decreased with training and anabolic steroid treatment (p less than 0.05). After the training period isoproterenol increased the maximum velocity of the cardiac contractile element significantly more (p less than 0.05) in the EG than in the ESG. Also SW increased in the EG (29%, p less than 0.001), but not in the ESG (-11%, NS). Endurance training increased the left ventricular end-diastolic and stroke volumes during isoproterenol infusion, but this training effect was attenuated by simultaneous anabolic steroid treatment (p less than 0.05 between the groups in both cases). During the isoproterenol test SVR decreased less in ESG than in EG (p less than 0.05 between).(ABSTRACT TRUNCATED AT 250 WORDS)
OBJECTIVE: To investigate to what extent and by what methods clinicians assess left ventricular (LV) function after an acute myocardial infarction (AMI) and how the results of the assessments relate to the use of angiotensin-converting enzyme (ACE) inhibitors; furthermore, to explore which main indications caused the clinicians to initiate ACE inhibitor therapy. DESIGN: From 16 hospitals we drew a sample of patients who were discharged with the diagnosis of AMI during a 3-month period in 1999/2000. Physicians in each hospital obtained the observed rate of use of cardiovascular drugs at discharge and also information on ejection fraction (EF) measurements. The results of the EF recordings were classified into three categories: >0.50, 0.40-0.50 and 0.50, 95 (24%) EF 0.40-0.50 and 87 (21%) EF 0.50. The main indication for starting ACE inhibitor therapy was heart failure (50%) followed by secondary prevention (42%). CONCLUSION: Measuring EF appears to be an important tool in the evaluation of AMI patients prior to discharge from hospital. Initiation of ACE inhibitor therapy related strongly to the results of the assessments.
Comment In: Scand Cardiovasc J. 2003 Jun;37(3):122-312881150
Heart failure (CHF) guidelines recommend mineralocorticoid receptor antagonists for all symptomatic patients treated with a combination of ACE inhibitors/angiotensin receptor blockers (ARBs) and beta-blockers. As opposed to both eplerenone trials, patients in RALES (spironolactone) received almost no beta-blockers. Since pharmacological properties differ between eplerenone and spironolactone, the prognostic benefit of spironolactone added to this baseline combination therapy needs clarification.
We included 4,832 CHF patients with chronic systolic dysfunction from the Norwegian Heart Failure Registry and the heart failure outpatients' clinic of the University of Heidelberg. Propensity scores for spironolactone receipt were calculated for each patient and used for matching to patients without spironolactone.
During a total follow-up of 17,869 patient-years, 881 patients (27.0 %) died in the non-spironolactone group and 445 (28.4 %) in the spironolactone group. Spironolactone was not associated with improved survival, neither in the complete sample (HR 0.82; 95 % CI 0.64-1.07; HR 1.03; 95 % CI 0.88-1.20; multivariate and propensity score adjusted respectively), nor in the propensity-matched cohort (HR 0.98; 95 % CI 0.82-1.18).
In CHF outpatients we were unable to observe an association between the use of spironolactone and improved survival when administered in addition to a combination of ACE/ARB and beta-blockers.
Nitrates may be beneficial in heart failure with preserved ejection fraction (HFpEF) by enhancing cGMP signaling and improving hemodynamics, but real-world data on potential efficacy are lacking.
We linked the Swedish Heart Failure Registry to national registries with International Classification of Diseases, Tenth Revision comorbidity diagnoses and demographic and socioeconomic data. In HFpEF, defined as left ventricular ejection fraction =40%, we derived propensity scores for nitrate use using 52 baseline variables. The association between nitrate use and all-cause mortality and the composite of all-cause mortality or first heart failure hospitalization was assessed in a cohort matched 2:1 untreated to treated based on age and propensity score. In the overall HFpEF cohort (n=19?047; mean [SD] age, 76  years; 46% women), nitrates were used in 17%, and the crude 1-year survival for treated versus untreated patients was 79% (95% confidence interval [CI], 78%-80%) versus 84% (95% CI, 83%-84%) respectively; hazard ratio was 1.48 (95% CI, 1.40-1.56; P
In 3 randomized controlled trials in heart failure (HF), mineralocorticoid receptor antagonists reduced mortality. The net benefit from randomized controlled trials may not be generalizable, and eplerenone was, but spironolactone was not, studied in mild HF. We tested the hypothesis that spironolactone is associated with reduced mortality also in a broad unselected contemporary population with HF and reduced ejection fraction, in particular New York Heart Association (NYHA) I-II.
We prospectively studied 18 852 patients (age 71±12 years; 28% women) with NYHA I-IV and ejection fraction
The ß-blockers carvedilol and metoprolol succinate both reduce mortality in patients with heart failure (HF), but the comparative clinical effectiveness of these drugs is unknown.
To investigate whether carvedilol is associated with improved survival compared with metoprolol succinate.
Cohort study of patients with incident HF with reduced left ventricular ejection fraction (LVEF) (=40%) who received carvedilol (n?=?6026) or metoprolol succinate (n?=?5638) using data from a Danish national HF registry linked with health care and administrative databases.
All-cause mortality (primary outcome) and cardiovascular mortality (secondary outcome) were analyzed using Cox regression with adjustment for a propensity score, derived from a range of clinical, socioeconomic, and demographic characteristics.
The mean (SD) age of the patients was 69.3 (9.1) years, 71% were men, and 51% were hospitalized at index HF diagnosis. During a median (interquartile range) 2.4 (1.0-3.0) years of follow-up, 875 carvedilol users and 754 metoprolol users died; the cumulative incidence of mortality was 18.3% and 18.8%, respectively. The adjusted hazard ratio for carvedilol users vs metoprolol users was 0.99 (95% CI, 0.88 to 1.11), corresponding to an absolute risk difference of -0.07 (95% CI, -0.84 to 0.77) deaths per 100 person-years. Estimates were consistent across subgroup analyses by sex, age, levels of LVEF, New York Heart Association classification, and history of ischemic heart disease. A higher proportion of carvedilol users achieved the recommended daily target dose (50 mg; 3124 [52%]) than did metoprolol users (200 mg; 689 [12%]); among patients who reached the target dose, the adjusted hazard ratio was 0.97 (95% CI, 0.72-1.30). A robustness analysis with 1:1 propensity score matching confirmed the primary findings (hazard ratio, 0.97 [95% CI, 0.84-1.13]). The adjusted hazard ratio for cardiovascular mortality was 1.05 (95% CI, 0.88-1.26).
These findings from real-world clinical practice indicate that the effectiveness of carvedilol and metoprolol succinate in patients with HF is similar.
County Council of Östergötland, Local Health Care Services in Central Östergötland, Primary Health Care Centres, Linköping University, Department of Medical and Health Sciences, Faculty of Health Sciences, Linköping, Sweden. Bjorn.Agvall@lio.se
Heart failure (HF) is a common condition with which high mortality, morbidity, and poor quality of life are associated. It has previously been shown that use of HF management programmes (HFMPs) in HF clinics can be beneficial. The purpose of this study was to evaluate if the use of HFMPs also has beneficial effects on HF patients in primary healthcare (PHC).
This is a randomized, prospective, open-label study including 160 patients from five PHC centres with systolic HF and a mean age of 75 years (standard deviation 7.8). In the intervention group, an intensive follow-up was performed by HF nurses and physicians providing information and education about HF and the optimization of HF treatment according to recognized guidelines. There was a significant improvement of composite endpoints in the intervention group. Significantly more patients with reduced N-terminal pro brain natriuretic peptide (P = 0.012), improved cardiac function (P = 0.03), fewer healthcare contacts (P = 0.04), and fewer emergency room visits and admittances (P = 0.0002 and P = 0.03, respectively) could be seen in the intervention group when compared with the control group.
The use of a HFMP in a PHC setting was found to have beneficial effects in terms of reducing the number of healthcare contacts and hospital admissions, and improving cardiac function in patients with systolic HF, even if the result should be interpreted with caution. It can therefore be recommended that HFMPs should be used in PHC.