RESUMEN
OBJECTIVES: We sought to characterize the clinical determinants of mortality in patients with angiographically diagnosed ischemic or nonischemic cardiomyopathy. BACKGROUND: Patients with ischemic cardiomyopathy may have a worse prognosis than patients with nonischemic cardiomyopathy. Few studies have assessed the effect of ischemic versus nonischemic etiology on outcomes. METHODS: We analyzed prospectively collected data on 3,787 patients with a left ventricular ejection fraction < or = 40% who underwent coronary angiography. Patients were considered to have ischemic cardiomyopathy (n = 3,112) if they had a history of myocardial infarction, percutaneous transluminal coronary angioplasty, coronary artery bypass graft surgery or at least one major epicardial coronary artery with > or = 75% stenosis; all others were considered to have nonischemic cardiomyopathy (n = 675). RESULTS: The median age, ejection fraction and proportion of patients with New York Heart Association functional class III or IV symptoms for the nonischemic and ischemic groups were 55 years versus 63 years, 27% versus 32% and 57% versus 25%, respectively. After adjustment for baseline clinical risk factors and presenting characteristics, ischemic etiology remained an important independent predictor of 5-year mortality (p < 0.0001). The extent of coronary artery disease was a better predictor of survival than ischemic or nonischemic etiology (log likelihood chi-square 700 vs. 675, respectively). CONCLUSIONS: Ischemic etiology is a significant independent predictor of mortality in patients with cardiomyopathy. However, the extent of coronary artery disease contributes more prognostic information than the clinical diagnosis of ischemic or nonischemic cardiomyopathy. Further research is needed to refine the clinical definition of ischemic cardiomyopathy so that physicians can appropriately prescribe treatment and accurately predict outcome.
Asunto(s)
Cardiomiopatías/etiología , Cardiomiopatías/mortalidad , Enfermedad Coronaria/complicaciones , Adulto , Anciano , Cateterismo Cardíaco , Cardiomiopatías/diagnóstico , Cardiomiopatías/fisiopatología , Distribución de Chi-Cuadrado , Angiografía Coronaria , Femenino , Humanos , Masculino , Persona de Mediana Edad , Valor Predictivo de las Pruebas , Pronóstico , Estudios Prospectivos , Factores de Riesgo , Volumen Sistólico , Análisis de Supervivencia , Función Ventricular IzquierdaRESUMEN
We reviewed the records of 242 patients admitted over 1 year with heart failure and an ejection fraction < or = 45% to assess the use of angiotensin-converting enzyme inhibitors. Most patients were treated with angiotensin-converting enzyme inhibitors. However, an important minority (8%) had no apparent reason for the lack of this treatment, highlighting the need for strategies to increase the use of these beneficial agents.
Asunto(s)
Inhibidores de la Enzima Convertidora de Angiotensina/uso terapéutico , Insuficiencia Cardíaca/tratamiento farmacológico , Disfunción Ventricular Izquierda/tratamiento farmacológico , Anciano , Contraindicaciones , Utilización de Medicamentos/estadística & datos numéricos , Femenino , Insuficiencia Cardíaca/etiología , Humanos , Masculino , Registros Médicos , Persona de Mediana Edad , Estudios Retrospectivos , Disfunción Ventricular Izquierda/complicacionesAsunto(s)
Inhibidores de la Enzima Convertidora de Angiotensina/administración & dosificación , Inhibidores de la Enzima Convertidora de Angiotensina/efectos adversos , Diuréticos/administración & dosificación , Diuréticos/efectos adversos , Insuficiencia Cardíaca/complicaciones , Insuficiencia Cardíaca/tratamiento farmacológico , Disfunción Ventricular Izquierda/tratamiento farmacológico , Disfunción Ventricular Izquierda/etiología , Anciano , Presión Sanguínea , Fármacos Cardiovasculares/uso terapéutico , Prescripciones de Medicamentos/estadística & datos numéricos , Femenino , Insuficiencia Cardíaca/fisiopatología , Humanos , Masculino , Persona de Mediana Edad , Sistema de Registros , Índice de Severidad de la Enfermedad , Factores Sexuales , Sístole , Disfunción Ventricular Izquierda/fisiopatologíaAsunto(s)
Electrocardiografía/normas , Hipertrofia Ventricular Izquierda/complicaciones , Infarto del Miocardio/diagnóstico , Distribución de Chi-Cuadrado , Diagnóstico Diferencial , Femenino , Humanos , Masculino , Persona de Mediana Edad , Infarto del Miocardio/complicaciones , Valor Predictivo de las PruebasRESUMEN
Arterial stiffness is an independent predictor of cardiovascular morbidity and mortality. Brain natriuretic peptide (BNP) and high-sensitivity C-reactive protein (hs-CRP) are considered as novel biomarkers that are useful in the prediction of early cardiovascular risk. We studied the relationship between carotid artery stiffness index beta and the cardiovascular biomarkers BNP and hs-CRP in 55 consecutive subjects. Carotid artery stiffness was assessed using the stiffness index beta derived from brachial artery blood pressure measurement and carotid ultrasonography. Venous blood samples were obtained for BNP and hs-CRP. Pearson's correlation coefficient suggested a strong bivariate relationship between carotid stiffness index beta and age (r=0.56, P<0.0001), BNP (r=0.45, P<0.004) and hs-CRP (r=0.26, P=0.06), respectively. On multiple regression analysis, significant correlations were found between carotid stiffness index beta and age (P=0.004), BNP (P=0.027) and hs-CRP (P=0.029). These findings suggest that there is a relationship between intra-cardiac pressures (measured by BNP), vascular inflammation (measured by hs-CRP) and vascular stiffness. Cardiovascular biomarkers are thus associated with functional parameters of the vascular tree.
Asunto(s)
Proteína C-Reactiva/metabolismo , Enfermedades de las Arterias Carótidas/diagnóstico por imagen , Enfermedades de las Arterias Carótidas/epidemiología , Péptido Natriurético Encefálico/sangre , Adulto , Biomarcadores/sangre , Arteria Braquial/fisiología , Enfermedades de las Arterias Carótidas/sangre , Femenino , Humanos , Masculino , Persona de Mediana Edad , Análisis Multivariante , Valor Predictivo de las Pruebas , Análisis de Regresión , Factores de Riesgo , UltrasonografíaRESUMEN
Cardiopulmonary exercise testing is commonly used to assess patients with heart failure. Analysis of expired gases during exercise requires the use of either a facemask or mouthpiece with nose clip. The authors sought to determine if the method of expired gas collection during exercise testing (facemask or mouthpiece) influences gas exchange measurements in patients with heart failure. Nine patients with heart failure performed two maximal treadmill tests. Expired gases were collected with a facemask in one exercise test and a mouthpiece in the other. There were no significant differences in exercise test duration, peak oxygen uptake, heart rate, respiratory exchange ratio, or perceived exertion during maximal exercise performed with the facemask when compared to the mouthpiece. Test subjects reported that the overall comfort of the facemask was significantly greater than that of the mouthpiece (P < .02). The method of expired gas collection during cardiopulmonary exercise testing does not significantly affect measures of gas exchange or exercise performance in patients with heart failure. Heart failure patients find the overall comfort of the facemask superior to that of the mouthpiece, but this comfort preference does not affect exercise performance.
Asunto(s)
Prueba de Esfuerzo , Insuficiencia Cardíaca/fisiopatología , Intercambio Gaseoso Pulmonar , Manejo de Especímenes/métodos , Femenino , Humanos , Masculino , Persona de Mediana Edad , Consumo de OxígenoRESUMEN
BACKGROUND: The benefit of angiotensin-converting enzyme (ACE) inhibitors on mortality in heart failure has been proved in randomized controlled trials. METHODS: We prospectively evaluated the prescribing of ACE inhibitors and the prescribing of target ACE inhibitor doses in 43 ambulatory patients with heart failure to identify differences in ACE inhibitor utilization among elderly and nonelderly patients. The prescribed ACE inhibitor dose and other variables were assessed by direct patient interview and information contained in the medical record. Telephone calls were conducted at 3 months to identify the occurrence of clinical events. RESULTS: Fewer elderly patients were prescribed target ACE inhibitor doses compared with nonelderly patients (21.4% vs 68.8%; p = 0.0136). Elderly patients were more likely to experience an event than nonelderly patients (11 vs 4; p = 0.0074). Elderly patients not receiving target ACE inhibitor doses demonstrated a trend toward more events than elderly patients who were at target doses. CONCLUSION: The data suggest that this group of elderly patients with heart failure who received lower ACE inhibitor doses appeared to be at higher risk for clinical events.
Asunto(s)
Inhibidores de la Enzima Convertidora de Angiotensina/administración & dosificación , Insuficiencia Cardíaca/tratamiento farmacológico , Anciano , Prescripciones de Medicamentos/estadística & datos numéricos , Utilización de Medicamentos/estadística & datos numéricos , Femenino , Estudios de Seguimiento , Hemodinámica/efectos de los fármacos , Humanos , Masculino , Observación , Proyectos Piloto , Estudios Prospectivos , Encuestas y Cuestionarios , Resultado del TratamientoRESUMEN
BACKGROUND: Exercise training, the major component of cardiac rehabilitation (CR), has been shown in previous trials to improve many pathophysiologic changes found in patients with left ventricular systolic dysfunction. It remains unproven whether exercise training improves survival. METHODS: By using the Duke Databank for Cardiovascular Disease, we identified patients with an ejection fraction < or = 40% and no recent myocardial infarction, congenital heart disease, or primary valvular disease who survived > or = 30 days after a cardiac catheterization (n = 1902). Participation in CR (n = 70) was identified through computer billing records. We developed a multivariable Cox proportional hazards regression model to estimate survival by using variables known to be independent predictors of survival in patients with systolic dysfunction. RESULTS: Patients participating in CR were less likely to be female or black and more likely to have a history consistent with ischemic cardiomyopathy. Participation in CR was associated with significantly improved survival after adjustment for baseline characteristics (hazard ratio, 0.39; 95% confidence interval, 0.15 to 0.62, P < .0001). Survival increased when patients participated in > 6 CR sessions (hazard ratio, 0.10; 95% confidence interval, 0.03 to 0.39; P < .0001). CONCLUSIONS: Participation in CR was associated with improved survival for patients with cardiomyopathy. There appears to be a dose response with improved survival benefit for patients with left ventricular systolic dysfunction participating in cardiac rehabilitation.
Asunto(s)
Terapia por Ejercicio , Disfunción Ventricular Izquierda/mortalidad , Disfunción Ventricular Izquierda/rehabilitación , Anciano , Distribución de Chi-Cuadrado , Femenino , Humanos , Masculino , Persona de Mediana Edad , Modelos de Riesgos Proporcionales , Estudios Prospectivos , Factores de Riesgo , Estadísticas no Paramétricas , Análisis de Supervivencia , Sístole , Resultado del TratamientoRESUMEN
BACKGROUND: Many patients with congestive heart failure do not receive the benefits of angiotensin-converting enzyme (ACE) inhibitors because of intolerance. We sought to determine the tolerability of an angiotensin II receptor blocker, candesartan cilexetil, among patients considered intolerant of ACE inhibitors. METHODS: Patients with CHF, left ventricular ejection fraction less than 35%, and history of discontinuing an ACE inhibitor because of intolerance underwent double-blind randomization in a 2:1 ratio to receive candesartan (n = 179) or a placebo (n = 91). The initial dosage of candesartan was 4 mg/d; the dosage was increased to 16 mg/d if the drug was tolerated. A history of intolerance of ACE inhibitor was attributed to cough (67% of patients), hypotension (15%), or renal dysfunction (11%). RESULTS: The study drug was continued for 12 weeks by 82.7% of patients who received candesartan versus 86.8% of patients who received the placebo. This 4.1% greater discontinuation rate with active therapy was not significant; the 95% confidence interval ranged from 4.8% more discontinuation with placebo to 13% more with candesartan. Titration to the 16-mg target dose was possible for 69% of patients who received candesartan versus 84% of those who received the placebo. Frequencies of death and morbidity were not significantly different between the candesartan and placebo groups (death 3.4% and 3.3%, worsening heart failure 8.4% and 13.2%, myocardial infarction 2.8% and 5.5%, all-cause hospitalization 12.8% and 18.7%, and death or hospitalization for heart failure 11.7% and 14.3%). CONCLUSIONS: Candesartan was well tolerated by this population. The effect of candesartan on major clinical end points, including death, remains to be determined.
Asunto(s)
Inhibidores de la Enzima Convertidora de Angiotensina/efectos adversos , Antihipertensivos/uso terapéutico , Bencimidazoles/uso terapéutico , Compuestos de Bifenilo/uso terapéutico , Insuficiencia Cardíaca/tratamiento farmacológico , Tetrazoles , Anciano , Inhibidores de la Enzima Convertidora de Angiotensina/uso terapéutico , Antihipertensivos/efectos adversos , Bencimidazoles/efectos adversos , Compuestos de Bifenilo/efectos adversos , Causas de Muerte , Relación Dosis-Respuesta a Droga , Método Doble Ciego , Esquema de Medicación , Femenino , Insuficiencia Cardíaca/diagnóstico , Insuficiencia Cardíaca/mortalidad , Hemodinámica/efectos de los fármacos , Humanos , Masculino , Persona de Mediana Edad , Proyectos Piloto , Tasa de Supervivencia , Disfunción Ventricular Izquierda/diagnóstico , Disfunción Ventricular Izquierda/tratamiento farmacológico , Función Ventricular Izquierda/efectos de los fármacosRESUMEN
AIMS: The reported prevalence of angiotensin-converting enzyme (ACE) inhibitor use in patients with heart failure varies considerably. Recent reports suggest that many patients who could benefit from such therapy are not receiving ACE inhibitors. The Study of Patients Intolerant of Converting Enzyme Inhibitors (SPICE) Registry was established to understand better the demographics, characteristics, and contemporary use of ACE inhibitors in an international registry. METHODS AND RESULTS: Between August 1996 and April 1997, each of 105 study centres from eight countries in North America and Europe was invited to review retrospectively the medical records of 100 consecutive patients with left ventricular ejection fractions =35%. The median age of the 9580 Registry patients was 66 years, 26% were women, the median ejection fraction was 27%, and the primary aetiology of left ventricular dysfunction was ischaemic (63%). Eighty percent of patients were receiving ACE inhibitors. The most common reason for non-use of ACE inhibitors was intolerance (9%). CONCLUSION: The SPICE Registry provides a contemporary description of the demographics and management of patients with documented left ventricular systolic dysfunction. The contemporary use of ACE inhibitors (80%) appears to be higher than previously reported and the main reason for non-use is perceived intolerance (9%).