RESUMO
UNLABELLED: Heart failure is a severe disease with a poor prognosis despite major therapeutic progresses achieved recently. A key factor is the high number of hospitalizations for heart failure, considered as being avoidable, since they are related to a lack of adequate management of the patients. Several therapeutic education programs focused on heart failure are in progress. Even though these programs aim at making patients an active agent managing the disease, data on patient's level of knowledge and experience regarding heart failure are scarce. The aim of our study was to analyze the patient's perception of the disease and his/her practices about this disease, as well as the treatments used. METHODS: we included 350 consecutive patients and analyzed their level of knowledge and experience using a questionnaire, as well as interviews performed by nurses and physicians. This initial assessment was followed by a second assessment after an 8-hours course in 2 days, made by the multidisciplinary education team of R. Dubos hospital (including physicians, nurses, physiotherapists, dietician). RESULTS: in contrast to tests assessing the knowledge on the disease, which were in overall satisfactory, the results on the level of knowledge on treatments and heart failure pathways were poor. The courses improve significantly the level of knowledge in all domains, whatever would the age and the level of patient's demand for information be. The analysis of the patient's conception of his/her own disease reveals the lack of knowledge on the severity of heart failure. Frequently, the effect of treatments is considered as poorly efficient, and a substantial fraction of these patients have underlying depressive moods. CONCLUSION: the understanding of the level of knowledge and the perception of the patient regarding his/her disease is primordial for setting educational structures and programs. However, the patient's conception of the disease is different from care providers. It is therefore essential to assess the patient's conception by an educational diagnosis prior to implement adapted education programs, in order to improve durably the patient's knowledge, at every age.
Assuntos
Atitude Frente a Saúde , Conhecimentos, Atitudes e Prática em Saúde , Insuficiência Cardíaca/psicologia , Educação de Pacientes como Assunto , Fatores Etários , Idoso , Idoso de 80 Anos ou mais , Depressão/psicologia , Escolaridade , Feminino , Insuficiência Cardíaca/complicações , Insuficiência Cardíaca/tratamento farmacológico , Insuficiência Cardíaca/fisiopatologia , Humanos , Masculino , Pessoa de Meia-Idade , Participação do Paciente , Autocuidado , Autoimagem , Inquéritos e QuestionáriosRESUMO
Beta-blocker therapy is actually recommended as first line therapy for systolic heart failure. However, beta-blocker have a low prescription rate comparatively to ACEI. Beta-blocker potential side effects as bradycardia, hypotension and especially acute decompensation could explain this under prescription. Clinical data could easily identify high-risk patients for hypotension or bradycardia but not high-risk patients for induced decompensation linked to beta-blocker therapy. BNP could identify these patients with a high sensitivity. Patients with BNP above 1000 pg/ml had a 40% risk of acute decompensation after introduction or increase of beta-blocker therapy. As a conclusion, clinicians must be very cautious for introducing or increasing Carvedilol therapy in patients with high BNP levels.
Assuntos
Antagonistas Adrenérgicos beta/efeitos adversos , Carbazóis/efeitos adversos , Insuficiência Cardíaca/sangue , Insuficiência Cardíaca/tratamento farmacológico , Peptídeo Natriurético Encefálico/sangue , Propanolaminas/efeitos adversos , Antagonistas Adrenérgicos beta/uso terapêutico , Idoso , Carbazóis/uso terapêutico , Carvedilol , Feminino , Humanos , Masculino , Valor Preditivo dos Testes , Propanolaminas/uso terapêutico , Fatores de RiscoRESUMO
Diagnosing or managing heart failure may still remain difficult. BNP and NT proBNP are neurohormones specifically secreted by myocytes. They have proved their effectiveness to improve clinician's diagnostic accuracy for diagnosing heart failure. BNP use is now recommended by European Society of Cardiology guidelines but multiplication of publications about BNP and NTProBNP show new possible applications for natriuretic peptides.
Assuntos
Insuficiência Cardíaca/sangue , Insuficiência Cardíaca/diagnóstico , Peptídeo Natriurético Encefálico/sangue , Doença Aguda , Análise Química do Sangue/métodos , Seguimentos , Humanos , PrognósticoRESUMO
Unstable angina is a serious condition, difficult to diagnose in the emergency room. Clinical, electrocardiographic and biological signs (increased troponine) are not sensitive. The authors set out to assess whether measuring B natiuretic peptide in the emergency room was more sensitive for identifying symptomatic coronary lesions. One hundred and twenty patients admitted to the emergency room for chest pain compatible with the diagnosis of unstable angina and a normal ECG were included in this prospective study. All patients underwent coronary angiography during their hospital admission. The sensitivities of troponine at a threshold of 0.4 ng/ml and of brain natiuretic peptide (BNP) at a threshold of 10 pg/ml in this population were 66% and 92% respectively. The use of troponine and BNP together provided better results than troponine and BNP alone for the identification of patients with chest pain with significant coronary lesions.
Assuntos
Angina Instável/sangue , Angina Instável/diagnóstico , Peptídeo Natriurético Encefálico/sangue , Troponina I/sangue , Biomarcadores/sangue , Dor no Peito/diagnóstico , Angiografia Coronária , Eletrocardiografia , Serviço Hospitalar de Emergência , França , Humanos , Pessoa de Meia-Idade , Valor Preditivo dos Testes , Estudos Prospectivos , Curva ROC , Sensibilidade e Especificidade , Estatísticas não ParamétricasRESUMO
OBJECTIVES: To determine if B-type natriuretic peptide (BNP) measurement could be useful in determination of functional capacity in patients suffering from chronic heart failure. BACKGROUND: Evaluating functional capacity is a crucial factor in the follow-up of patients with chronic heart failure. There are numerous methods for measuring functional capacity and their relative merits remain under discussion. Clinical classifications are very subjective and other methods are difficult to use in clinical practice. METHODS: We evaluated functional capacity in 151 consecutive patients using the 6-min walk test. All patients were clinically classified using the New York Heart Association (NYHA) classification. We measured BNP plasma levels using a bedside BNP test. RESULTS: Six minute walk test performance decreased through NYHA classes 1 to 4 (469+/-87, 411+/-82, 325+/-83 and 196+/-63 m, respectively, P<0.01) and BNP levels increased through NYHA classes 1 to 4 (26.3+/-7.2, 73+/-13, 401+/-74 and 924+/-84 pg/ml, respectively, P<0.001). There was a significant correlation between 6-min walk test performance and BNP plasma levels (R=0.69 P<0.001) and a weaker correlation between BNP and left ventricular ejection fraction (R=0.45 P<0.04). In some patients there was a mismatch between NYHA classification and 6-min walk test performance. In all cases BNP could correct the clinical estimation of functional capacity. When we divided the patients into three sub-groups within each NYHA class, we showed that using BNP could better define functional capacity in patients suffering from chronic heart failure in NYHA classes I to III. CONCLUSION: The measurement of BNP levels thus usefully supplements the clinical examination. The existence of bedside BNP testing methods facilitates its use in routine clinical practice. It also permits easier follow-up of patients with chronic heart failure.
Assuntos
Fator Natriurético Atrial/sangue , Insuficiência Cardíaca/sangue , Insuficiência Cardíaca/fisiopatologia , Adolescente , Antagonistas Adrenérgicos beta/administração & dosagem , Adulto , Idoso , Idoso de 80 Anos ou mais , Inibidores da Enzima Conversora de Angiotensina/administração & dosagem , Fator Natriurético Atrial/efeitos dos fármacos , Biomarcadores/sangue , Carbazóis/administração & dosagem , Carvedilol , Doença Crônica , Diuréticos/administração & dosagem , Relação Dose-Resposta a Droga , Seguimentos , França/epidemiologia , Furosemida/administração & dosagem , Insuficiência Cardíaca/classificação , Humanos , Incidência , Lisinopril/administração & dosagem , Pessoa de Meia-Idade , Peptídeo Natriurético Encefálico , Propanolaminas/administração & dosagem , Índice de Gravidade de Doença , Espironolactona/administração & dosagem , Volume Sistólico/fisiologia , Resultado do TratamentoRESUMO
Natriuretic Peptides like BNP or NT Pro BNP are diagnostic and prognostic makers largely used in clinical practice. Ageing may increase these peptides, especially in case of comorbidities like renal failure or hypertension and require adjustment for age. Diagnostic value of natriuretic peptides seems however preserved in elderly people.
Assuntos
Insuficiência Cardíaca/diagnóstico , Peptídeo Natriurético Encefálico/sangue , Proteínas do Tecido Nervoso/sangue , Fragmentos de Peptídeos/sangue , Adulto , Fatores Etários , Idoso , Idoso de 80 Anos ou mais , Biomarcadores/sangue , Estudos de Coortes , Eletrocardiografia , Feminino , Imunofluorescência , Insuficiência Cardíaca/sangue , Insuficiência Cardíaca/complicações , Humanos , Hipertensão/complicações , Falência Renal Crônica/complicações , Estudos Longitudinais , Masculino , Pessoa de Meia-Idade , Prognóstico , Radioimunoensaio , Valores de Referência , Fatores Sexuais , Fatores de TempoRESUMO
Prognosis for heart failure is linked to patient's compliance. Compliance is also dependent from patient education about his disease and treatment. Therapeutic education could be done in a community hospital but needs a lot of time. However, therapeutic education for heart failure patients becomes more and more essential in clinical practice and improves patient knowledge and implication and hospitalization duration.
Assuntos
Insuficiência Cardíaca/terapia , Educação de Pacientes como Assunto , Idoso , Idoso de 80 Anos ou mais , Terapia por Exercício , França , Hospitais Comunitários , Humanos , Estilo de Vida , Equipe de Assistência ao Paciente , Cooperação do Paciente , Inquéritos e Questionários , Fatores de TempoRESUMO
Medical research is an important part of medical art. From Hippocratis to hypothesis ... resume research processes. Medical trials could be done or managed by community hospitals but it implies several collaborations with university structures. Even it is sometimes difficult to do, improvement of medical science and patient management through publications and communications are the ultimate goal of such trials....
Assuntos
Pesquisa Biomédica , Hospitais Comunitários , Cardiologia , Ensaios Clínicos como Assunto , França , Humanos , Estudos Multicêntricos como Assunto , Sociedades MédicasRESUMO
Shortness of breath is a common cause of consultation in the emergency unit. Therefore, it is essential to diagnose cases of cardiac failure. This may be difficult in some cases. The authors set out to assess the value of measuring brain natiuretic peptide in this context. Brain natiuretic peptide (BNP) was measured by an ultrafast method (Biosite/BMD) on arrival of 125 patients to the emergency unit. The results were then compared with the diagnoses made in the emergency unit and those of the hospital discharge summary. Nearly 18% of patients were wrongly classified in the emergency room; 1/3 were falsely diagnosed as cardiac failure and 2/3 were not recognised initially as having cardiac failure. In 90% of patients, in particular in the group wrongly considered as not having cardiac failure, BNP measurement could have helped correct the mistake. The optimal threshold value of BNP for diagnosis of cardiac failure in this study was 300 pg/mL, with positive and negative predictive values of 92.4 and 90.2%, respectively.
Assuntos
Fator Natriurético Atrial/análise , Biomarcadores/análise , Serviços Médicos de Emergência , Insuficiência Cardíaca/diagnóstico , Idoso , Idoso de 80 Anos ou mais , Diagnóstico Diferencial , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Peptídeo Natriurético Encefálico , Alta do Paciente/estatística & dados numéricos , Valor Preditivo dos Testes , Estudos Prospectivos , Valores de Referência , Sensibilidade e EspecificidadeRESUMO
It is well known that atrial fibrillation can lead to heart failure, and is attributed to rapid ventricular rate (tachycardia-induced cardiomyopathy). Some recent studies suggest the possible existence of an intrinsic left-ventricular factor related to atrial fibrillation, irrespective of other elements. In order to demonstrate the implication of this factor, we measured B-type Natriuretic Peptide, known as a functional marker of left-ventricular dysfunction, in 40 consecutive patients with chronic non-valvular atrial fibrillation, with low ventricular rate and absence of clinical heart failure or echocardiographic left-ventricular dysfunction. In all patients, Brain Natriuretic Peptide (BNP) plasma level was high and dramatically decreased 24 h after external electrical cardioversion (61.4 pg/ml before cardioversion, 23.5 pg/ml 1 day after cardioversion, P<0.002). Our study demonstrates that atrial fibrillation, in absence of high ventricular rate, induces an asymptomatic cardiac alteration that is not detectable by echocardiography.
Assuntos
Fibrilação Atrial/sangue , Cardioversão Elétrica , Frequência Cardíaca/fisiologia , Peptídeo Natriurético Encefálico/sangue , Fibrilação Atrial/fisiopatologia , Fibrilação Atrial/terapia , Biomarcadores/sangue , Distribuição de Qui-Quadrado , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Estudos Prospectivos , Estatísticas não ParamétricasRESUMO
To examine the ability of myocardial contractile reserve (MCR) assessment to predict the improvement of left ventricular ejection fraction with treatment by carvedilol, a prospective study was undertaken in 85 patients with chronic heart failure and left ventricular ejection fraction < 45%. Low dose dobutamine echocardiography (DSE), a 6-min walk test and measured brain natriuretic peptide (BNP) were assessed in all the patients. Patients were separated into two groups. Group A were patients without any myocardial reserve and group B patients with a myocardial contractile reserve defined as an increment of more than 20% of the resting left ventricular ejection fraction during dobutamine infusion. The two groups differed for percentage of ischemic cardiomyopathy (67.8 in group A vs. 29.7% in group B P = 0.028), 6-min walk test performance (respectively, 343 vs. 415 meters P < 0.05) and BNP plasma levels (respectively, 184.5 vs. 70.1 P < 0.02) but not for left ventricular ejection fraction or NYHA class. During DSE, MCR and heart rate variation was higher in group B than in group A. At the end of the follow up, LVEF increased and NYHA class decreased in group B but not in group A. In multivariate analysis the existence of MCR could predict the improvement of LVEF with treatment by carvedilol. In our study, studying MCR could help to predict patients who will improve their LVEF with carvedilol prior to the administration of the treatment.
Assuntos
Antagonistas Adrenérgicos beta/uso terapêutico , Carbazóis/uso terapêutico , Insuficiência Cardíaca/tratamento farmacológico , Contração Miocárdica/fisiologia , Propanolaminas/uso terapêutico , Volume Sistólico/efeitos dos fármacos , Disfunção Ventricular Esquerda/tratamento farmacológico , Biomarcadores/sangue , Carvedilol , Ecocardiografia , Ecocardiografia sob Estresse , Teste de Esforço , Feminino , Insuficiência Cardíaca/fisiopatologia , Humanos , Masculino , Pessoa de Meia-Idade , Peptídeo Natriurético Encefálico/sangue , Valor Preditivo dos Testes , Estudos Prospectivos , Estatística como Assunto , Volume Sistólico/fisiologia , Resultado do Tratamento , Disfunção Ventricular Esquerda/fisiopatologiaRESUMO
The demonstration of a myocardial contractile reserve with low dose dobutamine is an emerging imaging technique in patients with dilated cardiomyopathy. This contractile reserve is correlated with a better prognosis and enables identification of subgroups of patients who could increase their left ventricular ejection fractions under carvedilol. A review of the published literature shows that the method does not expose patients to major risk, providing patients are selected and carefully monitored during the procedure. Complementary studies of larger numbers of patients are required to confirm its value as a prognostic and therapeutic marker in patients with dilated cardiomyopathy.
Assuntos
Agonistas Adrenérgicos beta/administração & dosagem , Cardiomiopatia Dilatada/diagnóstico por imagem , Dobutamina/administração & dosagem , Ecocardiografia sob Estresse , Contração Miocárdica/efeitos dos fármacos , Cardiomiopatia Dilatada/fisiopatologia , HumanosRESUMO
Chronic heart failure is linked to high rate of death and hospitalization. Some studies have highlighted the beneficial effect of heart failure clinics on morbidity and mortality. We have developed this type of structure at CHR Dubos since 3 years and we have recently created an heart failure clinic (10 beds). It's based on a concept including an experienced medical and nurse team, patient's and patient's family education and evaluation of the structure.
Assuntos
Institutos de Cardiologia/organização & administração , Insuficiência Cardíaca , Ambulatório Hospitalar/organização & administração , Idoso , França , Insuficiência Cardíaca/terapia , Humanos , Educação de Pacientes como AssuntoRESUMO
Treatment with non-steroid anti-inflammatory drugs associated with a prostaglandin analogue is common, but the potential cardiovascular effects are largely unknown. The authors report a case of myocardial necrosis and anaphylactic shock due to treatment with diclofenac and misoprostol. The reintroduction of the treatment in hospital led to the recurrence of the initial cutaneous and cardiac symptoms in this patient.
Assuntos
Anafilaxia/induzido quimicamente , Antiulcerosos/efeitos adversos , Diclofenaco/efeitos adversos , Misoprostol/efeitos adversos , Miocárdio/patologia , Idoso , Humanos , Masculino , NecroseRESUMO
Inhibitors of serotonin uptake are drugs prescribed without recognised cardiovascular risk. The authors report a case of torsades de pointes following Citalopram ingestion. In this patient, the proof of reintroduction in a hospital environment resulted in prolongation of the QT interval. Screening of patients for acquired or congenital long QT intervals is therefore necessary before starting treatment with Citalopram.
Assuntos
Antidepressivos de Segunda Geração/efeitos adversos , Citalopram/efeitos adversos , Torsades de Pointes/induzido quimicamente , Antidepressivos de Segunda Geração/uso terapêutico , Citalopram/uso terapêutico , Feminino , Humanos , Síndrome do QT Longo/complicações , Pessoa de Meia-IdadeRESUMO
The authors report sequential association during the same general anaesthetic of coronary bypass surgery on the beating heart and surgery of an abdominal aortic aneurysm. Two aorto-coronary bypass grafts were carried out without cardiopulmonary bypass using the two pediculated internal mammary arteries (without manipulation of the ascending aorta), followed, after closure of the chest and monitoring in the operating theatre for one hour, by reinstallation of the patient for treatment of an infra-renal abdominal aortic aneurysm by classical prosthetic implantation. The postoperative course was uncomplicated. Sequential management of coronary revascularisation without cardiopulmonary bypass and aortic aneurysmal lesions during the same anaesthetic provides an alternative to classical two-stage surgery in selected patients.
Assuntos
Aneurisma da Aorta Abdominal/cirurgia , Ponte de Artéria Coronária/métodos , Idoso , Anestesia Geral , Aneurisma da Aorta Abdominal/diagnóstico por imagem , Angiografia Coronária , Humanos , Masculino , Artéria Torácica Interna/transplante , Fatores de Tempo , Resultado do TratamentoRESUMO
Brain natiuretic peptide (BNP) is a hormone secreted specifically by the left ventricular myocytes. Its concentration is correlated with the severity of symptomatic or asymptomatic left ventricular dysfunction. The measurement of BNP has several applications from the screening of populations to the monitoring of the effects of treatment and the evaluation of the prognosis of cardiac failure. The emergence of new methods of rapid measurement will enable its usage as a routine investigation in the near future. Large scale clinical trials are, however, required to confirm the hopes raised by this new marker of left ventricular dysfunction.
Assuntos
Insuficiência Cardíaca/fisiopatologia , Peptídeo Natriurético Encefálico/fisiologia , Animais , Biomarcadores/análise , Ventrículos do Coração , Humanos , Miocárdio/metabolismo , Peptídeo Natriurético Encefálico/análise , Disfunção Ventricular Esquerda/fisiopatologiaRESUMO
BACKGROUND AND AIMS: A significant decrease of left ventricular ejection fraction (LVEF) at stress has been reported with 99Tc(m) gated single-photon emission computed tomography (gSPECT) in severe myocardial stunning up to 1 h after exercise. This study was designed to show whether 201Tl gSPECT can measure LVEF evolution from rest to stress in routine examination and give additional information to perfusion interpretation since acquisition starts immediately after stress test. METHODS: Post-exercise and rest 201Tl gSPECT were performed in 187 patients with suspected coronary artery disease. Myocardial perfusion was quantified by 20-segment analysis. Patients were divided into four groups according to their summed perfusion score, reversibility rate and electrocardiographic findings, i.e. in order of severity: I = normal perfusion, II = fixed defect owing to a myocardial infarction, III = full reversible ischaemia, and IV = partial reversible ischaemia. LVEF was calculated by Germano's automatic algorithm. RESULTS: Normal subjects (n = 29) and infarcted patients (n = 34) showed a significant LVEF increase between rest and stress, +7 +/- 9% and +5 +/- 7% respectively. In full reversible ischaemic patients (n = 46), stress LVEF showed no increase (+1 +/- 8%) and this group was statistically different from both group I and group II. Furthermore, when ischaemia was partially reversible (n = 31), LVEF decreased significantly (-3 +/- 8%), particularly when exercise tests were abnormal (-4 +/- 8%). Group IV was statistically different from groups I and II. CONCLUSIONS: Good agreement exists between the severity of ischaemic perfusion pattern and LVEF degradation at stress, which is consistent with previously published data using 99Tc(m) gSPECT. Additionally, the use of 201Tl for immediate post-exercise imaging allows the observation of a physiological LVEF increase in normal and infarcted patients.
Assuntos
Circulação Coronária/fisiologia , Compostos Radiofarmacêuticos , Volume Sistólico/fisiologia , Radioisótopos de Tálio , Tomografia Computadorizada de Emissão de Fóton Único/métodos , Adulto , Idoso , Idoso de 80 Anos ou mais , Algoritmos , Doença das Coronárias/diagnóstico por imagem , Eletrocardiografia , Teste de Esforço , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Miocárdio Atordoado/diagnóstico por imagem , Angiografia Cintilográfica , Descanso/fisiologiaRESUMO
ECG-gated myocardial scintigraphy (Gspect) is a recent method of assessing myocardial perfusion, left ventricular ejection fraction and regional wall motion in a single investigation. It reduces the time required for the evaluation of coronary patients by radionucleide cardiology. Many reports have validated the measurement of the left ventricular ejection fraction compared with other methods. However, there are fewer series reporting the results of regional wall motion. The authors compared segmental wall motion by Gspect after injecting Thallium or Mibi and by transthoracic echocardiography in 47 patients or 423 myocardial segments. The concordance of score (normal, hypokinetic, akinetic, dyskinetic) was 75% (Kappa = 0.538). If analysis was limited to a normal-abnormal differentiation (binary analysis) it increased to 83%. When perfusion was taken into consideration, it was 81% (normal perfusion), 63% (mild hypoperfusion) and 70% (moderate and severe hypoperfusion). This concordance improved in binary analysis respectively to 85, 74 and 86% respectively. When the typs of segment was taken into consideration, concordance varied from 57 to 100%. The concordances were 74% for Thallium and 78% for Mibi scintigraphy, improving to 82% and 85% respectively in binary analysis. Thus, analysis of LV regional wall motion by Gspect is comparable to transthoracic echocardiography. This result, completed by measurement of LV ejection fraction and of myocardial perfusion, provides a method of evaluation of coronary patients in a single investigation.
Assuntos
Ecocardiografia/métodos , Imagem do Acúmulo Cardíaco de Comporta , Contração Miocárdica , Volume Sistólico , Idoso , Doença das Coronárias/diagnóstico , Doença das Coronárias/diagnóstico por imagem , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Sensibilidade e Especificidade , Função Ventricular EsquerdaRESUMO
One hundred patients underwent early coronary angiography (average 20.5 days) after coronary bypass surgery between 1994 and 1996. The indications in clinically asymptomatic patients were: study of double mammary grafts, non respect of the preoperative plan (grafts not available, technical difficulties), and/or postoperative ECG changes. 12.1% of internal mammary grafts and 18.2% of the saphenous vein grafts were considered to be non-fractional: due to occlusion in 3 and 11.9%, due to poor implantation site (persistence of a distal stenosis): 3 and 0.8% respectively. After investigations to detect ischaemia in the region concerned or persistence of a critical lesion on a non-revascularised main artery, 26 complementary angioplasties were performed: 3 on internal mammary grafts, 4 on saphenous vein grafts and 19 on the native vessels. Surgery alone resulted in complete revascularisation in 70% and its association with cardiological interventional techniques increased the value to 85%. The association of coronary bypass surgery and transluminal angioplasty may therefore result in optimal revascularisation. This should reduce the morbidity rate, the number of hospital admissions (recurrent ischaemia and reoperation) and improve survival. However, the exact modalities of this combined revascularisation remain to be defined.