Beta-adrenergic blockade in the treatment of congestive heart failure

Although chronic sympathetic activation provides inotropic and chronotropic support to the failing heart, such activation may also have deleterious effects, including the direct cardiotoxic effects of catecholamines, activation of the renin-angiotensin-adosterone system and an increase in myocordial oxygen demand. These observations indicate that beta-blockade might be beneficial in the treatment of heart failure. This suggestion is receiving growing support from clinical trials, which show that beta-blockade improves the clinical and functional status of patients with heart failure resulting from dilated cardiomyopathy or ischaemic heart disease. These trials have also indicated beta blocking agents are much safer in patients with heart failure than was previously thought, provided that they are introduced at a low dose and titrated carefully. Newer beta blocking agents have ancillary properties that may be important in the treatment of heart failure. Bucindolol and carvedilol have vasodilating effects that may upload the failing heart, and carvedilol also has antiproliferative and antioxidant properties not shared by other beta blocking agents. Carvedilol is the only beta blocking agent that has reduced overall mortality in patients with heart failure in controlled clinical trials, and it also reduces hospitalization and improves the global assessment of patients. A large comparative trial against other beta blocking agents to confirm that these benefits are unique to carvedilol is about to be launched. Further clinical experience is required to determine the optimum use of carvedilol in the treatment of heart failure. The results obtained so far with carvedilol suggest that the management of heart failure is about to undergo a significant change(AU)

Cardiovascular problems in the hypertensive diabetic patient

Cardiovascular disease is a major cause of morbidity and mortality in patients with diabetes and has become the subject of intensive recent investigation. One hundred years following the initial description of the relationship between diabetes and anginal chest pain, major scientific organizations in the United States have come together and focused much attention on this topic. The importance of heart disease and diabetes has been emphasised in a recent American Heart Association Scientific Statement and accompanying editorial written jointly by the American Diabetes Association (ADA), the National Heart, Lung and Blood Institute, the Juvenile Diabetes Foundation International, the National Institute of Diabetes and Digestive and Kidney Diseases, and the American Heart Association. Hypertension is not only a risk factor for the development of cardiovascular disease, but is also a strong, independent predictor of renal disease and retinopathy. Cardiovascular problems that result from diabetes and hypertension include stroke, coronary artery disease, hypertensive cardiomyopathy, and congestive heart failure. (AU)

The prevalence, aetiology and treatment of congestive cardiac failure in Antigua and Barbuda

A retrospective review of the cases of congestive heart failure admitted to Holberton Hospital in Antigua in 1995 and 1996 was undertaken. Two hundred and ninety-three (293) patients were identified by International Statistical Classification of Diseases, 10th revision (ICD-10) coding as having congestive cardiac failure in the period but only 138 charts were either available or fitted the definition of congestive cardiac failure and these provided the basis for this analysis. The average age of patients admitted for congestive cardiac failure was 69 years (range: 5 months to 99 years), and 63 percent were female. The aetiology of congestive cardiac failure was hypertension (41 percent), ischaemia (3 percent), valvular (12 percent), alcohol related (2 percent), idiopathic (5 percent) and mixed (7 percent). Treatment included diuretics (95 percent), angiotensin converting enzyme inhibitors (78 percent), digoxin (75 percent), nitrates (34 percent), calcium channel blockers (25 percent), other vasodilators (7 percent) and antiarrhythmics (5 percent). Of those with congestive heart failure, diabetes was present in 38 percent, atrial fibrillation in 19 percent, renal insufficiency in 17 percent, elevated cholesterol in 11 percent, obesity in 9 percent and tobacco use in 7 percent. The in-hospital mortality in the 2-year period was 17.4 percent (females 15 percent, males 22 percent, 11 percent < 65 years, 20 percent > 65 years, 14 percent for those with 1 to 3 admissions and 83 percent for those with > 3 admissions, 19 percent for those with atrial fibrillation and 16 percent for those without). The prevalence of congestive cardiac failure utilizing the data analysed in this study (138 patients) was 0.21 percent of the population of 40 to 65-year-age group and 4 percent in those > 65 years of age. The patients in this study represented only those with New York Heart Association (NYHA) classes 3 and 4, hence the true prevalence would be higher than recorded here. Congestive cardiac failure is emerging as a significant health problem in Antigua and Barbuda.(AU)

Systolic left ventricular dysfunction detected by echocardiography: demographics and aetiology - abstract

The aim of this retrospective study was to determine the demographic features and causes of heart failure in patients presenting a tertiary care institution: 65 patients aged >16 years with an ejection fraction (EF) < 40 percent, undergoing echocardiography during a two-year period, 1992-94, were included in the study. The mean age was 60 ñ 12 years, 68 percent were male, 50 percent and 42 percent were African and East Indian, respectively. The prevalence of diabetes and hypertension was 40 percent and 45.3 percent respectively. The majority of patients were in NYHA class II or III. The mean left ventricular ejection fraction (LVEF) was 29.7 ñ 8.6 percent. There was no correlation between NYHA class and LVEF at initial presentation. The underlying causes of heart failure were coronary artery disease (CAD) (42 percent), idiopathic dilated cardiomyopathy (10.9 percent), hypertensive heart disease (9.4 percent), alcohol related dilated cardiomyopathy (7.8 percent), valvular heart disease (7.8 percent), myocarditis (1.6 percent) and hypertrophic cardiomyopathy (1.6 percent). The dominant primary cause could not be determined in 18.8 percent. LVEF was similarly depressed in the two major ethnic groups and in the ischaemic and non-ischemic cardiomyopathy groups. We concluded that CAD was the most common cause of LV systolic dsyfunction and that LVEF was not related to ethnicity, aetiology or severity of symptoms. (AU)

Peripartum cardiomyopathy and arterial embolism

A severely pre-eclamptic patient developed peripartum cardiomyopathy and bilateral femmoral emboli. Medical therapy for cardiac failure was commenced prior to delivery by caesarean section. Bilateral femoral embolectomy was performed on the sixth postpartum day. (AU)

Primary infantile haemangioendothelioma of the liver

A three-week-old female infant who was admitted to the University Hospital of the West Indies in severe congestive cardiac failure developed haematological abnormalities and died two days later. At autopsy, she was found to have multicentric haemangioendotheliomas of the liver. Intractable cardiac failure and haematological abnormalities are typical manifestations of this infantile vascular tumour of the liver which may obscure the diagnosis (AU)

Pulmonary artery banding for ventricular septal defect in infancy

Experiencing with pulmonary artery banding in three ill infants with large ventricular septal defects is reported for the first time from the Commonwealth Caribbean. There was a successful outcome in all three cases. There was a minimal follow-up of one year. It is suggested that the systolic pressure gradient across the band, after a satisfactory steady state has been achieved, may be a useful additional measurement in the evaluation of the resultant haemodynamic state. (AU)

Diffuse pulmonary fibrosis and blackfat-tobacco smoking in Guyana

The clinical features and epidemiology of diffuse pulmonary fibrosis in Guyana have been investigated. The condition is limited to East Indians and is characterised by progressive dyspnoea leading to pulmonary heart-disease and congestive heart-failure. 19 hospital patients studied, and 7 others radiographically confirmed, had all smoked "blackfat" tobacco, a variety which is not widely used.(Summary)

Heart disease in Jamaica

The cardiac cases admitted to an adult male and female ward of the University College Hospital of the West Indies during 1956 and '57 have been analysed and the autopsy incidence of heart lesions in the first 1258 cases seen in the Pathology Department of the University College of the West Indies has been reviewed. (AU)