Levosimendan in intensive care and emergency medicine: literature update and expert recommendations for optimal efficacy and safety.

The inodilator levosimendan, in clinical use for over two decades, has been the subject of extensive clinical and experimental evaluation in various clinical settings beyond its principal indication in the management of acutely decompensated chronic heart failure. Critical care and emergency medicine applications for levosimendan have included postoperative settings, septic shock, and cardiogenic shock. As the experience in these areas continues to expand, an international task force of experts from 15 countries (Austria, Belgium, China, Croatia, Finland, France, Germany, Greece, Hungary, Italy, the Netherlands, Spain, Sweden, Switzerland, and the USA) reviewed and appraised the latest additions to the database of levosimendan use in critical care, considering all the clinical studies, meta-analyses, and guidelines published from September 2019 to November 2021. Overall, the authors of this opinion paper give levosimendan a "should be considered" recommendation in critical care and emergency medicine settings, with different levels of evidence in postoperative settings, septic shock, weaning from mechanical ventilation, weaning from veno-arterial extracorporeal membrane oxygenation, cardiogenic shock, and Takotsubo syndrome, in all cases when an inodilator is needed to restore acute severely reduced left or right ventricular ejection fraction and overall haemodynamic balance, and also in the presence of renal dysfunction/failure.

Early enteral nutrition in critically ill patients: ESICM clinical practice guidelines

PURPOSE: To provide evidence-based guidelines for early enteral nutrition (EEN) during critical illness. METHODS: We aimed to compare EEN vs. early parenteral nutrition (PN) and vs. delayed EN. We defined "early" EN as EN started within 48 h independent of type or amount. We listed, a priori, conditions in which EN is often delayed, and performed systematic reviews in 24 such subtopics. If sufficient evidence was available, we performed meta-analyses; if not, we qualitatively summarized the evidence and based our recommendations on expert opinion. We used the GRADE approach for guideline development. The final recommendations were compiled via Delphi rounds. RESULTS: We formulated 17 recommendations favouring initiation of EEN and seven recommendations favouring delaying EN. We performed five meta-analyses: in unselected critically ill patients, and specifically in traumatic brain injury, severe acute pancreatitis, gastrointestinal (GI) surgery and abdominal trauma. EEN reduced infectious complications in unselected critically ill patients, in patients with severe acute pancreatitis, and after GI surgery. We did not detect any evidence of superiority for early PN or delayed EN over EEN. All recommendations are weak because of the low quality of evidence, with several based only on expert opinion. CONCLUSIONS: We suggest using EEN in the majority of critically ill under certain precautions. In the absence of evidence, we suggest delaying EN in critically ill patients with uncontrolled shock, uncontrolled hypoxaemia and acidosis, uncontrolled upper GI bleeding, gastric aspirate >500 ml/6 h, bowel ischaemia, bowel obstruction, abdominal compartment syndrome, and high-output fistula without distal feeding access.

Levosimendan: current data, clinical use and future development.

Levosimendan is an inodilator indicated for the short-term treatment of acutely decompensated severe chronic heart failure, and in situations where conventional therapy is not considered adequate. The principal pharmacological effects of levosimendan are (a) increased cardiac contractility by calcium sensitisation of troponin C, (b) vasodilation, and (c) cardioprotection. These last two effects are related to the opening of sarcolemmal and mitochondrial potassium-ATP channels, respectively. Data from clinical trials indicate that levosimendan improves haemodynamics with no attendant significant increase in cardiac oxygen consumption and relieves symptoms of acute heart failure; these effects are not impaired or attenuated by the concomitant use of beta-blockers. Levosimendan also has favourable effects on neurohormone levels in heart failure patients. Levosimendan is generally well tolerated in acute heart failure patients: the most common adverse events encountered in this setting are hypotension, headache, atrial fibrillation, hypokalaemia and tachycardia. Levosimendan has also been studied in other therapeutic applications, particularly cardiac surgery - in which it has shown a range of beneficial haemodynamic and cardioprotective effects, and a favourable influence on clinical outcomes - and has been evaluated in repetitive dosing protocols in patients with advanced chronic heart failure. Levosimendan has shown preliminary positive effects in a range of conditions requiring inotropic support, including right ventricular failure, cardiogenic shock, septic shock, and Takotsubo cardiomyopathy.

[Epidemiology, diagnosis, and treatment of giant pleomorphic adenomas of the parotid gland]. / Pleomorphe Riesenadenome der Ohrspeicheldrüse: Epidemiologie, Diagnostik und Therapie.

Pleomorphic adenomas of the parotid gland can be slowly growing over the course of many years and may reach an enormous and disfiguring size associated with significant morbidity of the patients. To our knowledge, over the last 80 years 20 cases of giant pleomorphic adenomas (weight 1.2-26.5 kg) have been reported. These tumors occurred predominantly in women (90%). The mean period from initial clinical manifestation until definitive surgical treatment was 20.7 years. The mean age of the patients at the time of surgery was 58.9 years. Malignant transformation occurred in 15.8% of cases. It is likely that the reasons for delayed treatment are the patient's fear of surgery on the one hand, and insufficient medical advise on the other. We report on a 77 year old female who had a 40-year history of a growing parotid tumor that weighed 3.9 kg after resection. The implications of this case for diagnosis and treatment of giant pleomorphic adenomas, and a review of the world literature on these unusual parotid tumors, are presented.

[The use of the BrainLAB Kolibri navigation system in endoscopic paranasal sinus surgery under local anaesthesia. An analysis of 35 cases]. / Einsatz des Brainlab-Kolibri-Navigationssystems bei der endoskopischen Nasennebenhöhlenchirurgie in Lokalanästhesie. Erfahrung an 35 Patienten.

BACKGROUND: As a result of technological advances, 3D-navigation systems are playing an increasingly important role in paranasal sinus and anterior skull base surgery. PATIENTS AND METHODS: The BrainLAB Kolibri navigation system (BrainLAB, Heimstetten, Germany) was used in the surgical management of chronic sinusitis and nasal polyposis in 35 patients. Surgery was performed under local anaesthesia. In order to compare this technique with traditional methods, 35 additional patients underwent conventional surgery. A clinical plausibility test using specific anatomical landmarks was performed to evaluate intraoperative navigation accuracy. In addition, a standardised questionnaire was used to document setup and registration times. Standardised rating scales helped assess whether the system can make surgery safer. RESULTS: It took approximately 5.8 min to set up the navigation system. The time required for system and patient positioning, including the attachment of the headband, was 4.2 min on average. Patient registration with the z-touch system was completed after an average of 4.2 min. It took an average of approximately 8.1 min to register a patient using the soft-touch system. The use of the navigation system increased the total time for preparation and surgery by approximately 50% in comparison to the conventional technique. An average accuracy of 1.5-2.3 mm in all three planes was measured. Participating surgeons felt that the system made surgery considerably safer. CONCLUSIONS: The BrainLAB Kolibri navigation system offers good accuracy, a short setup time and an easy registration technique. The combination of these qualities and intuitive operation make this system a suitable option for routine use in paranasal sinus surgery. As a result of its compactness, the BrainLAB Kolibri navigation system can be moved easily between different operating rooms and can also be used in small facilities (e.g. container operating theatres in field hospitals).

[Can preoperative fine-needle aspiration of parotid tumors pose problems for a definitive histological diagnosis?]. / Kann die präoperative Feinnadelpunktion bei Parotistumoren die definitive histologische Diagnose erschweren?

INTRODUCTION: Fine-needle aspiration cytology (FNAC) is a minimally invasive procedure that offers high specifity and acceptable sensitivity in the preoperative diagnosis of parotid tumors. FNAC provides information that can be particularly valuable in surgical planning and patient education. In some cases, it may even help prevent unnecessary surgery. After an FNA procedure, on rare occasions, morphological changes in the tumor may be observed and can make a definitive histological examination difficult or even impossible. METHODS: Histopathological changes in parotid tumors after preoperative FNAC are described on the basis of a case report and a survey of the literature. RESULTS: In rare cases, puncture-induced histopathological changes, such as hyalinization of the subepithelial stroma, necrosis and squamous metaplasia, so extensive that a definitive histological diagnosis is difficult, are observed. In the present case report, fine-needle aspiration of a 3 x 2 cm tumor, which had been classified as malignant on the basis of cytological findings, resulted in complete necrosis and made a definitive histological diagnosis impossible. Similar cases have been described by other authors in recent years. DISCUSSION: In rare cases, histological changes in the tumor tissue can occur after an FNA procedure, making a definitive histological examination difficult or even impossible. When a preoperative FNAC is performed, the pathologist in charge should be advised accordingly. In addition, patients should be informed about this infrequent risk before undergoing the procedure.

Endotoxin pretreatment modifies peristalsis and attenuates the antipropulsive action of adrenoceptor agonists in the guinea-pig small intestine.

The action of endotoxin to alter gastrointestinal motility in vivo may reflect a direct effect on the gut or result from vascular and other systemic manifestations of this sepsis model. Here we examined whether in vivo pretreatment of guinea-pigs with endotoxin modifies peristalsis in the isolated gut and influences the antipropulsive action of adrenoceptor agonists. Distension-induced peristalsis was recorded in fluid-perfused segments of the small intestine taken from animals pretreated intraperitoneally with endotoxin (1 mg kg(-1)Escherichia coli lipopolysaccharide) or vehicle 4 or 20 h before. Clonidine, adrenaline, noradrenaline, dopamine and dobutamine inhibited peristalsis with differential potency. Endotoxin pretreatment lowered the peristaltic pressure threshold and altered other parameters of baseline peristalsis in a time-related manner. The potency and efficacy of clonidine to inhibit peristalsis were markedly decreased after endotoxin administration, while the potency of the other test drugs was less attenuated. The antipropulsive action of clonidine in control segments was reduced by yohimbine and prazosin, whereas in segments from endotoxin-pretreated animals it was antagonized by yohimbine but not prazosin. We conclude that systemic endotoxin pretreatment of guinea-pigs modifies baseline peristalsis by an action on the gut and inhibits the antipropulsive action of adrenoceptor agonists through changes in adrenoceptor activity.

Jailhouse Blues revisited.

BACKGROUND: Over the past decades a number of studies have appeared on suicide among persons in jail and prison remand settings, and sentenced prisoners. In these papers contradictory views concerning the relation between suicide risk and length of custody were published. METHODS: This article reports on a study that investigated all suicides (n=206) in all 29 Austrian jails and prisons between 1975 and 1996. The authors demonstrate the necessity to calculate the hazard that reflects the suicide risk in relation to time. RESULTS: The results suggest three different periods of high suicide risk: immediately after admission and 2 months thereafter for prisoners on remand; for long-term prisoners the suicide risk correlates with the length of the sentence and slightly increases with the time of custody. CONCLUSIONS: With this knowledge, suicide prevention programmes in prisons and jails could be made more effective and economic.

Sufentanil potentiates the inhibitory effect of epinephrine on intestinal motility.

OBJECTIVE: The aim of our study was to evaluate the effect of the combination of different catecholamines and sufentanil on peristalsis of the isolated guinea pig small bowel in vitro. DESIGN: In vitro study on excised guinea pig small-bowel segments (8-10 segments per substance tested). SETTING: Laboratory for experimental studies at the University. SUBJECTS: Isolated guinea pig small-bowel segments. INTERVENTIONS: Excised segments of guinea pig small bowel were mounted in a tissue bath (37 degrees C) in Tyrode's solution and bubbled with carbogen (95% O2/5% CO2). The lumina were perfused with Tyrode's solution at 0.5 ml/min. The test drugs (epinephrine, norepinephrine, dobutamine, sufentanil, and a combination of these catecholamines with sufentanil) were added to the tissue bath and peristalsis recorded via changes in the intraluminal pressure. One-way and two-way ANOVA were used for statistical analysis. MEASUREMENTS AND RESULTS: All the tested substances, both individually and in combination, inhibited intestinal peristalsis in a dose-dependent manner. High doses resulted in a complete blockade of peristalsis. Preexposure of the segments to sufentanil at 0.1 nM barely influenced the effects of the catecholamines on peristalsis. However, sufentanil at 0.3 nM enhanced the antiperistaltic activity of epinephrine in a supraadditive manner, whereas the effect on norepinephrine and dobutamine was less pronounced. CONCLUSIONS: Our experimental data suggest that the combination of epinephrine and sufentanil might be the worst choice for the intensive care setting. This is due to its pronounced inhibitory effect on peristalsis in vitro at moderate and higher concentrations.

[Did suicidal behavior have relevance for prison suicide?]. / Welche Relevanz hat die dokumentierte Suizidalität in Gefangenensuiziden?

OBJECTIVE: Suicides in correctional institutions occur more frequently than in the general population. Inmate suicide rates have been increasing in many countries during the last decades, possibly reflecting a selection of highly endangered individuals with a high prevalence of mental disorders. This study investigates all suicides in all correctional institutions of Austria during the last 25 years. METHODS: All available personal files of inmates who had committed suicide in the 29 Austrian prisons between January 1st, 1975, and December 31st, 1999, were analysed. Beside personal characteristics and circumstances of custody, information concerning psychiatric disorders and the inmate's history of suicidal behavior was included. RESULTS: 220 personal files of 250 suicides were available and included. Half of all suicides had a history of attempted suicide and 37 % had expressed suicidality. Referral to psychiatric consultants was known in 48.6 % and about 37 % received psychopharmacological treatment. Based on these frequent signs of psychiatric illness and vulnerability, possible implications of these results for psychiatric services of the correctional system to improve suicide prevention are discussed. CONCLUSIONS: Obvious signs of suicidality play an important role in vulnerability profiles for jail and prison suicides. Any signs of suicidality (st. p. attempted suicide, verbal suicide threat, self-harm) should have the consequence of further psychiatric care.

[Relationship between symptoms of depression and anxiety and the quality of life in multiple sclerosis]. / Zusammenhänge zwischen Depression, Angst und Lebensqualität bei Multipler Sklerose.

BACKGROUND: Health-related Quality of Life (QoL) is gaining increasing influence as a relevant evaluation criterium in clinical research. Several studies have investigated QoL in patients suffering from multiple sclerosis (MS) and the impact of therapeutic interventions on QoL. However, the influence of psychiatric complications, which occur frequently in MS (e.g. depression and anxiety disorders), on the autoassessment of QoL are hardly ever considered. METHODS: Symptoms of depression and anxiety were rated in 74 outpatients with definite MS. The health-related QoL was assessed and set into relation to physical disability (measured with the Expanded Disability Status Scale) and duration of the disease. The results were compared with 74 normal controls of the same age. RESULTS: A highly significant relationship between emotional state (Zerssen-scale), depression (Zung-depression-scale), anxiety (Zung anxiety scale) and Quality of Life was evident. CONCLUSIONS: Clinical trials assessing Quality of Life in MS patients should consider the frequency of psychiatric comorbidity and the influence of depression and anxiety disorders on self-rated Quality of Life.

[Deprivation versus importation: a model explaining the increase of suicide rates in custody]. / Deprivation versus Importation: ein Erklärungsmodell für die Zunahme von Suiziden in Haftanstalten.

High suicide rates in jail, lock-up or prison settings have given rise to a debate about whether suicides result chiefly from the type of people confined, or from the types of places they are confined in, the types of confinement. This is summarily framed by the terms of an associated debate in criminology, between importation and deprivation theory. This paper describes the importation versus deprivation theory, concerning the circumstances in Austrian prisons and jails. The article reports on all completed suicides over the period from 1947 to 1999 (n = 410). The increase of suicide rates in Austrian jails and prisons is significant over the last fifty years. While the rate was stable between 1947 and 1975, we have a significantly increasing rate since 1975. In 1975 there was an important legislational reform of the criminal law in Austria. The implications of this reform are discussed in the light of the importation/deprivation theory.

Relationship between depression, anxiety and quality of life: a study of stroke patients compared to chronic low back pain and myocardial ischemia patients.

The prevalence of anxiety disorders and depression is assessed as between 20 and 50% following stroke. Depressive persons tend to give their overall life situation a worse rating than their relatives or physicians because of negative cognitions. Nevertheless, research concerning Quality of Life (QoL) after stroke hardly ever takes into account the methodological bias of assessing QoL only by self-rating. The aim of this study was to point out the important relationship between depression, anxiety and the autoassessment of QoL. QoL was markedly affected in the poststroke patients and in the chronic low back pain and myocardial ischemia patients, and it was rated worst by the most seriously depressed subjects. Clinical studies focusing on the ever more significant evaluation criterion 'health-related QoL' after stroke should take into account the high prevalence of anxiety and depressive symptoms and their major influence on the patients' self-evaluated QoL.

Low potential of dobutamine and dopexamine to block intestinal peristalsis as compared with other catecholamines.

OBJECTIVE: Catecholamines are frequently used in critically ill patients to restore stable hemodynamics and to improve organ perfusion. One effect of short-term or long-term administration of catecholamines may be inhibition of propulsive motility in the intestine. We therefore analyzed the effect of dopexamine, dobutamine, and dopamine on ileal peristalsis and compared their action with that of epinephrine and norepinephrine, which have long been known to suppress intestinal peristalsis. DESIGN: In vitro study on excised guinea pig ileum segments. SETTING: Laboratory for experimental studies at the University. SUBJECTS: Isolated guinea pig ileum. INTERVENTIONS: Segments of ileum excised from guinea pigs were mounted in a tissue bath in Krebs-Henseleit solution and bubbled with 95% oxygen/5% CO2. Luminal perfusion with the same solution was performed at a rate of 0.35 mL/min. The bath temperature was kept at 36.5 degrees C. Peristalsis was recorded via changes in the intraluminal pressure. The drugs under investigation (dopamine, epinephrine, norepinephrine, dobutamine, and dopexamine) were added to the tissue bath. MEASUREMENTS AND MAIN RESULTS: Low concentrations of each catecholamine, except epinephrine, caused a decrease in the pressure threshold, which reflects a stimulatory effect on peristalsis. Higher catecholamine concentrations caused a concentration-related increase in the threshold, cumulating in a complete block of peristalsis. The rank order of inhibitory potency was epinephrine > norepinephrine > dopamine > dobutamine approximately dopexamine. Dobutamine and dopexamine were about 500-fold less active than epinephrine in suppressing peristalsis. CONCLUSIONS: This study shows that dobutamine and dopexamine have the least potential to block propulsive motility in the intestine, whereas epinephrine demonstrates the most adverse inhibitory effect. Because at low concentrations dobutamine and dopexamine even stimulate peristalsis, these drugs appear to be superior compared with other catecholamines with regard to their direct effects on intestinal motility.

Preoperative treatment with recombinant human erythropoietin or predeposit of autologous blood in women undergoing primary hip replacement.

BACKGROUND: Controversy exists about the advantages of predeposit of autologous blood (PDAB), and whether more comfortable blood conservation regimens may yield comparable results. To test the hypothesis that preoperative treatment with recombinant human erythropoietin (rHuEPO) with or without acute concomitant normovolaemic haemodilution (ANHD) is as effective as PDAB in reducing allogeneic blood transfusions, we conducted a prospective randomised study in women undergoing primary hip replacement. METHODS: Sixty consecutive female patients scheduled for primary hip replacement and suitable for PDAB were randomly assigned to one of 3 groups. Group I (EPO) and II (ANHD) received 600 U/kg rHuEPO s.c. and 100 mg iron saccharate i.v. on day 14 and, if needed, on day 7 before surgery. Additionally, in group II acute normovolaemic haemodilution (ANHD) was implemented after induction of anaesthesia. In group III (PDAB) conventional PDAB up to 3 U, without volume replacement but with concomitant oral iron therapy, was performed starting 4 weeks before surgery. RESULTS: The blood conservation methods resulted in a comparable net gain of red cells in all 3 groups until the day of surgery. Because of the withdrawal of autologous blood, haemoglobin values before surgery were lower in the PDAB group than in the EPO and ANHD groups, and during surgery were lower in the PDAB and ANHD groups than in the rHuEPO-only group. Applying moderate ANHD in conjunction with preoperative rHuEPO treatment did not yield an incremental decrease in allogeneic transfusions. There was no difference between the groups in the number of patients who received allogeneic transfusions or in the total number of allogeneic units transfused. CONCLUSIONS: Withdrawal of autologous blood is associated with lower pre- and intraoperative haemoglobin levels when compared to preoperative augmentation of red cell mass using rHu-EPO. As a measure to reduce allogeneic transfusion requirements, preoperative treatment with rHuEPO may be as effective as standard predeposit of autologous blood in women undergoing primary hip replacement, but requires less preoperative time.

Perioperative myocardial cell injury: the relationship between troponin T and cortisol.

STUDY OBJECTIVE: To investigate whether there is an association between Troponin T (TnT), reflecting myocardial cell injury, and cortisol, reflecting the degree of surgical trauma and associated stress, in light of our recent evaluation of TnT as a marker of perioperative myocardial cell injury. DESIGN: Prospective, cohort study. PATIENTS: 70 patients (67.4 +/- 8.7 yrs) with definite or at-risk coronary artery disease (CAD) undergoing elective noncardiac surgery (vascular n = 38, abdominal n = 21, orthopedic n = 8) with general (n = 63) or regional (n = 4) anesthesia with postoperative on-demand analgesia. MEASUREMENTS AND MAIN RESULTS: Morning blood samples for TnT (upper limit of normal: <0.2 ng/mL), CK-MB (reference range

[Psychopharmaceuticals and breast feeding]. / Psychopharmaka in der Stillzeit.

The frequency of postnatal mental disorders requiring psychopharmacological treatment raises the question whether breast feeding can be recommended in some cases. This paper summarizes recent information regarding benefits and risks of breast feeding for infants of psychopharmacologically treated mothers. If a mother insists upon breast feeding, a careful risk-benefit-consideration has to take place. New results indicate that the advantages of breast feeding can outweight the given risks of maternal pharmacotherapy, if minimal necessary drug-doses of an agent with a small amount of passage into milk are prescribed. Monitoring of the serum-levels is advisable especially during the first three months. The nursing infant has to be closely controlled for any adverse effects.

[Assessment of custodial suicide risk--jail and prison suicides in Austria 1975-1996]. / Gefangenensuizide: Hinweise zur Abschätzung der Suizidgefahr- Suizide in Osterreichs Haftanstalten 1975-1996.

OBJECTIVE: Although incarceration is a high-risk situation for suicide all over the world, hardly any results have been published concerning the situation of custodial suicide in German-speaking countries. METHODS: We investigated the case notes of all suicides occuring in Austrian prisons between 1975 and 1996 (n= 207). Beside an evaluation of gender and preferred methods of suicide the suicide risk of different circumstances of custody was studied. Suicide rates of distinguishable, important subgroups of prisoners were calculated using the official statistical data of the Ministry of Justice. RESULTS: The suicide rate for people on remand and offenders classified as mentally ill was 231/100,000 vs. 191/100,000, that was about eight times higher than the suicide rate in Austria's general population. The suicide rate for sentenced offenders was 80/100,000, about three times as high as the suicide rate in Austria's general population (1980-1990: 26.4/100,000). The suicide risk increased with the length of the announced sentence. CONCLUSIONS: The suicide rate in custody was highest for prisoners on remand and mentally ill offenders. Female offenders had a high suicide risk, too. The common assumption that the suicide risk in jails and prisons is highest shortly after admission should be confirmed based on better methodology or be reconsidered.

Natriuretic peptides in patients with diastolic dysfunction due to idiopathic dilated cardiomyopathy.

AIMS: The degree of systolic dysfunction does not always correlate with functional impairment in patients with congestive heart failure. In contrast, diastolic dysfunction correlates well with functional impairment. In heart failure, both elevation of N-terminal proatrial natriuretic peptide and B-type natriuretic peptide are markers of a poor prognosis. METHODS: We investigated 32 patients (26 male, 6 female; mean age 55+/-2 years) with dilated cardiomyopathy and sinus rhythm. M-mode echocardiography and 2D-echocardiography were carried out in each patient. Pulsed-wave Doppler inflow signals were obtained and the following parameters were measured: maximal E wave and maximal A wave velocity, E/A ratio, E wave deceleration time, A wave deceleration time. Immediately after echocardiography blood samples were collected from patients in the supine position. N-terminal proANP and brain natriuretic peptide were measured using a radioimmuno assay. RESULTS: The left ventricular ejection fraction was 34+/-1%, the left ventricular end-diastolic diameter on M-mode echocardiography was 68+/-1 mm, while left atrial diameter was 45+/-1 mm. Univariate analysis revealed a significant correlation between both left atrial diameter and ejection fraction and N-terminal proANP and brain natriuretic peptide. All transmitral Doppler parameters showed a significant correlation with N-terminal proANP and brain natriuretic peptide. On forward stepwise regression analysis, left atrial diameter and ejection fraction were able to predict both N-terminal proANP and brain natriuretic peptide. However, of the diastolic parameters only the E/A ratio remained significant. Mildly symptomatic patients differed significantly from severely symptomatic patients in all Doppler parameters. Mildly symptomatic patients had significantly lower levels of N-terminal proANP (0.571+/-0.079 vs 2.282+/-0.340 nmol. l(-1);P<0.001) and brain natriuretic peptide (51+/-14.8 vs 474.2+/- 86.8 pg. ml(-1);P<0. 001). CONCLUSION: There is a close relationship between natriuretic peptides and diastolic Doppler parameters of left ventricular filling in patients with dilated cardiomyopathy. There is also a significant difference between patients with mild and severe functional impairment regarding both natriuretic peptides and transmitral Doppler parameters.