Intraventricular vortex properties in nonischemic dilated cardiomyopathy.

Vortices may have a role in optimizing the mechanical efficiency and blood mixing of the left ventricle (LV). We aimed to characterize the size, position, circulation, and kinetic energy (KE) of LV main vortex cores in patients with nonischemic dilated cardiomyopathy (NIDCM) and analyze their physiological correlates. We used digital processing of color-Doppler images to study flow evolution in 61 patients with NIDCM and 61 age-matched control subjects. Vortex features showed a characteristic biphasic temporal course during diastole. Because late filling contributed significantly to flow entrainment, vortex KE reached its maximum at the time of the peak A wave, storing 26 ± 20% of total KE delivered by inflow (range: 1-74%). Patients with NIDCM showed larger and stronger vortices than control subjects (circulation: 0.008 ± 0.007 vs. 0.006 ± 0.005 m(2)/s, respectively, P = 0.02; KE: 7 ± 8 vs. 5 ± 5 mJ/m, P = 0.04), even when corrected for LV size. This helped confining the filling jet in the dilated ventricle. The vortex Reynolds number was also higher in the NIDCM group. By multivariate analysis, vortex KE was related to the KE generated by inflow and to chamber short-axis diameter. In 21 patients studied head to head, Doppler measurements of circulation and KE closely correlated with phase-contract magnetic resonance values (intraclass correlation coefficient = 0.82 and 0.76, respectively). Thus, the biphasic nature of filling determines normal vortex physiology. Vortex formation is exaggerated in patients with NIDCM due to chamber remodeling, and enlarged vortices are helpful for ameliorating convective pressure losses and facilitating transport. These findings can be accurately studied using ultrasound.

Rapid carvedilol up-titration in hospitalized patients with left ventricular systolic dysfunction--data from the Carvedilol in Hospital: Up-titration Limits after Acute Patients Admission registry.

BACKGROUND AND OBJECTIVE: The safety of rapid carvedilol up-titration in patients with depressed left ventricular ejection fraction (LVEF) is unknown. The aim of the present work was to assess whether carvedilol can be used safely and rapidly up-titrated before hospital discharge in patients with left ventricular systolic dysfunction, with or without heart failure symptoms. METHODS: We studied 611 patients with LVEF less than 0.4 in whom carvedilol was used during hospital admission. RESULTS: Mean age was 66 years, 23% were women and 372 had symptoms of heart failure. Carvedilol was initiated 3 days after admission (median); 594 patients (97%) were discharged alive, 27 (5%) without beta-blockers. Carvedilol up-titration during admission was performed in 65%. The mean time of up-titration was 1 week, with a mean increase of 16 mg/day. The discharge dose was higher in younger patients and in those weighing more than 70 kg. Only 30 patients (5%) were re-admitted during the first month after discharge. At the end of follow-up (mean 2.3 years), 497 patients were alive and transplant-free (81%). Carvedilol mean daily dose at the end of follow-up was 32.4 +/- 22.2 mg and was related to the discharge dose. The absence of beta-blocker treatment at discharge was the most important independent predictor of long-term mortality (hazard ratio 3.1, 95% confidence interval 1.5-6.2, P = 0.002). CONCLUSION: Carvedilol up-titration is well tolerated in patients hospitalized with depressed LVEF, with or without heart failure, with a high compliance rate at discharge and in the long term.

Rapid carvedilol up-titration in hospitalized patients with systolic heart failure.

To determine whether carvedilol can be safely up-titrated before hospital discharge, we studied 372 consecutive patients with systolic heart failure who were being treated with carvedilol. Carvedilol was initiated a median of 3 days after admission, with a mean starting dose of 12 mg. Up-titration was performed in 67% of patients, with a mean increase of 16 mg and a mean discharge daily dose of 23 +/- 17 mg. Mean daily dose at the end of follow-up was 35.3 +/- 25.3 mg and it increased with higher discharge dose.