Acute Myocarditis Related to COVID-19: Comparison to SARS and MERS.

Myocardial involvement has been described during previous SARS and MERS outbreaks. Infection by SARS-CoV-2 (COVID-19) can range from asymptomatic to life-threatening multi-system disease. Heart involvement most commonly occurs during severe COVID-19 infection. Myocardial injury, based on elevated levels of myocardial enzymes, has been noted in up to 30% of patients with COVID-19 infection and could be a marker for worse prognosis. A few cases of possible myocarditis due to SARS-CoV-2 have been described, providing variable degree of evidence of direct myocardial involvement. We reviewed in detail those cases in comparison to relevant literature on SARS and MERS and attempted to draw initial conclusions in regard to clinical presentation, treatment and prognosis.

Length of exposure to the hospital environment is more important than antibiotic exposure in healthcare associated infections by methicillin-resistant Staphylococcus aureus: a comparative study

OBJECTIVES: Both total antimicrobial use and specific antimicrobials have been implicated as risk factors for healthcare-associated methicillin-resistant Staphylococcus aureus (HCA-MRSA) infection. The aims of this study were: (I) to explore predictors of a new HCA-MRSA infection in comparison with a new healthcare-associated methicillin-sensitive Staphylococcus aureus (HCA-MSSA); (II) to thoroughly assess the role of recent antibiotic use qualitatively and quantitatively. METHODS: The time-period for our study was from October 1997 through September 2001. Through applying strict criteria, we identified two groups of inpatients, one with a new HCA-MRSA infection and one with a new HCA-MSSA infection. We recorded demographic, clinical and antibiotic use-related data up to 30 days before the positive culture date. RESULTS: We identified 127 and 70 patients for each group, respectively. Two logistic regression models were carried out to assess the role of antimicrobial use (qualitatively and quantitatively). In model I, duration of hospital stay, presence of chronic wounds, aminoglycoside and fluoroquinolone use retained statistical significance. In model II, duration of hospital stay and history of intubation during the last month stood out as the only significant predictors of a subsequent HCA-MRSA infection. No significant differences in outcome were noted. CONCLUSIONS: The length of exposure to the hospital environment may be the best predictor of a new HCA-MRSA infection. Use of aminoglycosides and fluoroquinolones may also stand independently along with presence of chronic ulcers and surgical procedures. No independent association between quantitative antibiotic use and subsequent HCA-MRSA infection was documented.

Length of exposure to the hospital environment is more important than antibiotic exposure in healthcare associated infections by methicillin-resistant Staphylococcus aureus: a comparative study.

OBJECTIVES: Both total antimicrobial use and specific antimicrobials have been implicated as risk factors for healthcare-associated methicillin-resistant Staphylococcus aureus (HCA-MRSA) infection. The aims of this study were: (I) to explore predictors of a new HCA-MRSA infection in comparison with a new healthcare-associated methicillin-sensitive Staphylococcus aureus (HCA-MSSA); (II) to thoroughly assess the role of recent antibiotic use qualitatively and quantitatively. METHODS: The time-period for our study was from October 1997 through September 2001. Through applying strict criteria, we identified two groups of inpatients, one with a new HCA-MRSA infection and one with a new HCA-MSSA infection. We recorded demographic, clinical and antibiotic use-related data up to 30 days before the positive culture date. RESULTS: We identified 127 and 70 patients for each group, respectively. Two logistic regression models were carried out to assess the role of antimicrobial use (qualitatively and quantitatively). In model I, duration of hospital stay, presence of chronic wounds, aminoglycoside and fluoroquinolone use retained statistical significance. In model II, duration of hospital stay and history of intubation during the last month stood out as the only significant predictors of a subsequent HCA-MRSA infection. No significant differences in outcome were noted. CONCLUSIONS: The length of exposure to the hospital environment may be the best predictor of a new HCA-MRSA infection. Use of aminoglycosides and fluoroquinolones may also stand independently along with presence of chronic ulcers and surgical procedures. No independent association between quantitative antibiotic use and subsequent HCA-MRSA infection was documented.

An outbreak of hemodialysis catheter-related bacteremia with sepsis caused by Streptococcus agalactiae in a hemodialysis unit.

BACKGROUND: Rates of invasive group B Streptococcus (GBS; Streptococcus agalactiae) disease in adults are on the rise. Invasive GBS disease can be community- or healthcare-associated. We report an outbreak of GBS catheter-related bacteremia in a hemodialysis (HD) unit. MATERIALS AND METHODS: Two patients undergoing HD at the same outpatient HD unit were admitted on the same day (within a few hours of each other) with catheter-related GBS bacteremia. A retrospective study was undertaken at the HD unit to address risk factors for febrile illness on the last HD session day. A detailed questionnaire was completed by all HD patients treated on the same day as the two GBS patients and by all members of the nursing and medical staff. Medical and nursing records of the HD unit were reviewed, as well as infection control and catheter care practices. Patients and staff members submitted swabs for culture. RESULTS: No rectal or vaginal culture of any HD patient or staff member was positive for GBS. The development of recent febrile disease was significantly associated with the presence of a hemodialysis catheter (p=0.028) and care for more than 30min by a specific nurse during the last two HD sessions (p=0.007). CONCLUSIONS: We speculate that the GBS strain was transmitted from one patient to the other through the hands of medical personnel. No such outbreak has ever been reported in HD patients. The importance of strict infection control practices in HD units and the avoidance of catheters for long-term HD should be emphasized.

Gastric syphilis: a systematic review of published cases of the last 50 years.

The authors conducted a systematic review of the English literature for cases of Gastric Syphilis (GS) in the last 50 years. The 34 studies which met selection criteria included 52 patients with GS. Of the reviewed patients, only 13% had a history of syphilis diagnosis and 46% had prior or concurrent clinical manifestations of the disease. Epigastric pain/fullness was the most common presenting symptom (92%) and epigastric tenderness being the most common sign. Gastric bleeding of variable intensity was documented in 35% of the cases. In the radiologic examinations, fibrotic narrowing and rigidity of the gastric wall was the most common finding (43%), followed by hypertrophic and irregular folds, while in endoscopy the most common lesion types were multiple ulcerations (48%), nodular mucosa, and erosions. The antrum was the most commonly affected area (56%). The majority of the patients received penicillin (83%) with a rapid resolution of their symptoms. Seventeen percent of the patients were treated surgically either due to a complication or due to strong suspicion of infiltrating tumor or lymphoma. The nonspecific clinical, radiologic, and pathologic characteristics of GS can establish it as a great imitator of other gastric diseases. GS should be considered in the differential diagnosis in patients at risk for sexually transmitted diseases who present with abdominal complaints and unusual endoscopic lesions and no other diagnosis is made, irrespective of the presence of H. pylori. The absence of primary or secondary luetic lesions should not deter one from considering GS.

Long-term complete regression of nodal marginal zone lymphoma transformed into diffuse large B-cell lymphoma with highly active antiretroviral therapy alone in human immunodeficiency virus infection.

Since the introduction of combination antiretroviral therapy (cART), there has been a decrease in the incidence of non-Hodgkin lymphoma among the HIV-infected population and also significantly improved survival rates. We describe a remarkable case of a HIV-infected patient whose large B-cell lymphoma, most likely arising by transformation of a nodal marginal zone lymphoma, completely regressed with the use of cART alone. He remained disease-free for almost 3 years and he finally died from presumed flare up of his lymphoma. There are very few cases of spontaneous regression of lymphomas with cART alone in the HIV population. This is an extreme example of the significance of cART in improving survival in HIV-non-Hodgkin lymphoma and changing the face of the HIV epidemic in general.

Community-acquired methicillin-resistant Staphylococcus aureus as a cause of rapidly progressing pyelonephritis with pyonephrosis, necessitating emergent nephrectomy.

In this article, we describe the first, to our knowledge, reported case of severe bacteremic upper urinary tract infection with pyonephrosis-in the context of prior chronic urinary tract disease-caused by community-acquired methicillin-resistant Staphylococcus aureus (MRSA). The patient presented with fever and constitutional symptoms, and computed tomography revealed extensive renal parenchymal infection along with a staghorn calculus and dilatation of the pyelocalyceal system. His clinical condition rapidly deteriorated, and he developed uncontrollable sepsis, necessitating an emergent nephrectomy. Significant pyonephrosis was noted during surgery. Blood cultures yielded MRSA, and molecular analysis (by polymerase chain reaction) of the MRSA strains from blood and wound fluid showed that they were Panton-Valentine leukocidin positive and they also possessed SCCmecA type IV. Postoperatively, the patient was treated with intravenous vancomycin for 3 weeks and had a favorable outcome.

Amiodarone attenuates the proarrhythmic effects of dobutamine in patients with advanced congestive heart failure.

INTRODUCTION: The long-term use of positive inotropic pharmaceuticals in patients suffering from end-stage congestive heart failure (CHF) has been associated with increased mortality, presumed to be due to proarrhythmia. Oral amiodarone combined with intermittent dobutamine infusions (IDI), on the other hand, has been shown to increase survival. This study evaluated the effects of oral amiodarone on the arrhythmias caused by dobutamine in patients with advanced CHF. METHODS: Thirty patients with CHF, in New York Heart Association functional class III or IV despite optimal medical therapy, were treated with weekly 8-h infusions of dobutamine 10 Ig/kg/min. All patients were treated for 1 month with oral amiodarone, 400 mg/day, before initiation of IDI. A 24-h ambulatory electrocardiogram was recorded on the day before dobutamine infusion and repeated the next day, starting with the onset of infusion. RESULTS: The average heart rate on the 24-h ambulatory electrocardiogram was 72 +/- 14 beats/min before vs. 72 +/- 12 beats/min during IDI (p=1.000). Likewise, dobutamine did not increase the frequency of premature ventricular complexes (23 +/- 32 per h before vs. 42 +/- 69 per h during infusion, p=0.131), ventricular couplets (18 +/- 36 per 24 h vs. 17 +/- 28 per 24 h, p=0.859), or the incidence of non-sustained ventricular tachycardia (27% vs. 40%, p=0.383). No patient developed ventricular fibrillation or sustained ventricular tachycardia during or after IDI. CONCLUSIONS: Chronic low-dose oral amiodarone attenuates the proarrhythmic effects of dobutamine, increasing the safety of ambulatory IDI.

Long-term survival and outcomes after hospitalization for acute myocardial infarction complicated by cardiogenic shock.

BACKGROUND: Cardiogenic shock is the leading cause of death during hospitalization for acute myocardial infarction (MI). However, little data exist regarding the long-term outcomes of patients who survived the acute phase of MI and were discharged from the hospital. METHODS: We retrospectively reviewed the records of 81 consecutive patients referred for management of acute MI and cardiogenic shock to analyze their in-hospital and long-term outcomes. RESULTS: Mean systemic systolic and central venous pressures at presentation were 74 +/- 15 and 17 +/- 7 mm Hg, respectively. Intra-aortic balloon counterpulsation (IABC) was implemented in all patients for a mean of 88 +/- 83 hours. Thrombolytics were administered in 49% and mechanical ventilation applied in 46% of patients. Primary angioplasty could not be performed in any patient, while 17 patients later underwent myocardial revascularization during hospitalization. There were 37 in-hospital survivors (45.7%). The 1-year survival after discharge from the hospital was 87.6% in the overall population, versus 100% among patients who underwent in-hospital myocardial revascularization, versus 78.9% among nonrevascularized patients (p = 0.079). Over a mean follow-up of 85 +/- 47 mo, survival after discharge from the index hospitalization was 44.9% in the overall population, versus 56.2% among revascularized patients, versus 36.4% among nonrevascularized patients (p = 0.277). Heart failure developed in 51.6% of patients who were discharged from the hospital. CONCLUSIONS: In this single center analysis, the long-term survival after acute MI complicated by cardiogenic shock was high with nearly 50% of patients surviving free from heart failure.

Hemodynamic effects of levosimendan in acute myocardial infarction complicated by cardiogenic shock and high systemic vascular resistance.

BACKGROUND: Levosimendan (LEVO), a new inodilator, improves hemodynamic function in patients with decompensated heart failure and preserved arterial blood pressure. Data on its use in patients with cardiogenic shock (CS) are scarce. The present study was undertaken to evaluate the hemodynamic effects of supplemental therapy with levosimendan (LEVO) in acute myocardial infarction (MI) and refractory cardiogenic shock (CS). METHODS: In 25 patients presenting in CS after acute MI, LEVO was administered for 24 h in doses ranging between 0.05 and 0.20 microg/kg/min, as tolerated, preceded by 6-microg/kg over 10 min, in addition to catecholamines. Hemodynamic measurements were made before and 24 h after initiation of the LEVO infusion. RESULTS: Hemodynamic improvement was limited to 13 patients with systemic vascular resistances (SVR) > or =18 W. LEVO increased the cardiac index from 1.5+/-0.3 l/min/m2 to 2.1+/-0.4 l/min/m2 (P = 0.002) and cardiac power from 0.462+/-0.164 W to 0.645+/-0.179 W (P = 0.022), and decreased SVR from 23+/-5 to 21+/-6.7 Wood units (P = 0.001) and pulmonary capillary wedge pressure from 24+/-9 mmHg to 16+/-11 mmHg (P = 0.059). No hemodynamic improvement was observed during LEVO administration in 12 patients with SVR < 18 W. CONCLUSION: The hemodynamic benefit conferred by LEVO added to catecholamines in patients with CS after acute MI was limited to patients with high SVR.

Multicenter randomized trial of facilitated percutaneous coronary intervention with low-dose tenecteplase in patients with acute myocardial infarction: the Athens PCI trial.

OBJECTIVES: To examine the safety and efficacy of low-dose tenecteplase, administered before facilitated percutaneous coronary intervention (PCI) to restore Thrombolysis In Myocardial Infarction (TIMI) grade 2 or 3 blood flow in the infarct related artery (IRA) in patients with ST elevation myocardial infarction (STEMI) scheduled to undergo PCI with a shortest anticipated delay of 30 min. BACKGROUND: PCI preceded by administration of glycoprotein IIb/IIIa inhibitors, full-dose thrombolytics, or both, is associated with no benefit or a higher incidence of adverse events than PCI alone. METHODS: Patients with STEMI < 6 hr in duration were randomly assigned to PCI preceded by tenecteplase, 10 mg (facilitated PCI group, n = 143) versus standard PCI (control group, n = 141). All patients received aspirin and unfractionated heparin (70 IU/kg bolus) at time of randomization. Both groups received IIb/IIIa inhibitors in the catheterization laboratory and for at least 20 hr after PCI. RESULTS: The median door-to-balloon time was 122 min (91-175) in the facilitated PCI versus 120 min (89-175) in the control group. IRA patency on arrival in the catheterization laboratory was 59.5% in the facilitated PCI (24% TIMI-2, 35% TIMI-3), versus 37% in the control (8% TIMI-2, 29% TIMI-3) group (P = 0.0001). During hospitalization, 9 patients (6%) died in the facilitated PCI versus 5 patients (3.5%) in the control group (P = 0.572). A single patient in the facilitated PCI group suffered a non-fatal ischemic stroke. CONCLUSIONS: Facilitated PCI with low-dose tenecteplase in patients presenting with STEMI was associated with a high IRA patency rate before PCI.

Intra-aortic balloon counterpulsation for the treatment of myocardial infarction complicated by acute severe heart failure.

Intractable heart failure (HF) remains a leading fatal complication of acute myocardial infarction (AMI). Intra-aortic balloon pump (IABP) counterpulsation assists the failing left ventricle and accelerates the functional recovery of stunned myocardium. Despite its remarkable performance, the beneficial effects of the IABP in the setting of acute HF or cardiogenic shock complicating AMI have not been confirmed in a randomized clinical trial. Instead, large amounts of information have been collected in observational studies or in retrospective analyses of randomized trials of reperfusion strategies in patients with AMI. The strategy of "stabilize with IABP, treat with reperfusion, and transfer for complete revascularization" has, thus far, yielded the best outcomes, and every effort should be made to implement this strategy in all patients presenting with AMI and severe HF.

Intra-aortic balloon counterpulsation and delayed revascularization for myocardial infarction and shock in the absence of primary angioplasty: a treatment strategy with or without thrombolysis?

OBJECTIVE: When revascularization facilities are not available, thrombolytic therapy (TT) added to intra-aortic balloon counterpulsation (IABC) has been proposed as initial therapy for the management of patients presenting with postmyocardial infarction (MI) cardiogenic shock, followed by prompt transfer to another institution for revascularization. The use of TT in this setting, however, remains controversial. METHODS: We reviewed the records of 81 consecutive patients admitted with cardiogenic shock after acute MI and compared the outcomes of patients initially stabilized, including IABC as an adjunct to TT (IABC+TT group, n=40), with those patients initially stabilized with IABC and no TT (IABC group, n=41). RESULTS: The baseline characteristics of the two study groups were similar. The in-hospital and 6-month survival rates were 47.5 and 33.3% in the IABC+TT group versus 43.9 and 31.6% in the IABC group, respectively (NS). Except for mechanical ventilation more frequently required in the IABC group, other outcome measures were similar in both groups. The in-hospital (76.5 vs. 36.5%, P=0.008) and 6-month (60 vs. 25.4%, P=0.01) survival rates were significantly higher in patients who underwent delayed invasive revascularization, than in patients who underwent no invasive revascularization attempt. CONCLUSION: In patients presenting with acute MI and cardiogenic shock, TT as an adjunct to IABC added no therapeutic benefit when compared with IABC alone. In contrast, the survival of patients was significantly increased by delayed invasive revascularization in both treatment groups. These observations suggest that, when revascularization facilities are not available, stabilization with IABC, followed by prompt transfer for delayed revascularization to a tertiary care hospital, might be the preferred management strategy for patients presenting with post-MI cardiogenic shock.

Depressed coronary flow reserve is associated with decreased myocardial capillary density in patients with heart failure due to idiopathic dilated cardiomyopathy.

OBJECTIVES: We sought to examine the relationship between coronary flow reserve (CFR) and myocardial capillary density (MCD) in patients with idiopathic dilated cardiomyopathy, heart failure, and normal coronary arteries. BACKGROUND: Coronary flow reserve is depressed in patients with idiopathic dilated cardiomyopathy, particularly in those with end-stage congestive heart failure. METHODS: We studied 18 patients, 48 +/- 10 years of age, who had a mean New York Heart Association functional class of 2.9 +/- 1.3, mean left ventricular ejection fraction of 22 +/- 8%, and mean pulmonary capillary wedge pressure of 23 +/- 10 mm Hg. CFR measurements were made with a 0.014-inch pressure-temperature sensor-tipped guide wire placed in the distal left anterior descending coronary artery. Thermodilution curves were constructed in triplicate at baseline and during maximum hyperemia induced by intravenous adenosine. CFR was calculated from the ratio of mean transit times. Right heart endomyocardial biopsies were performed during the same procedure. Autopsied specimens from nonfailing hearts were used as controls. The tissue was histochemically stained with CD-34 for morphometric measurements of MCD. RESULTS: We observed a close linear relationship between CFR and MCD (r = 0.756, p = 0.0001). The MCD in 7 patients with a CFR >or=2.5 (73.2 +/- 16) was similar to that measured in normal control patients, (85 +/- 11, p = NS). In contrast, the MCD in 11 patients with a CFR <2.5 was 33.2 +/- 14, which was significantly lower than in patients with heart failure and normal CFR (73.2 +/- 16, p = 0.001) or in controls (85 +/- 11, p < 0.0001). CONCLUSIONS: A marked decrease in MCD was found in patients presenting with congestive heart failure as the result of idiopathic dilated cardiomyopathy and a depressed CFR.

Possible everolimus-induced, severe, reversible encephalopathy after cardiac transplantation.

Neurotoxicity is a common adverse effect of cyclosporine (CsA) in transplant recipients. Although most patients develop mild toxic manifestations, leukoencephalopathy with seizures, visual complications, psychiatric symptoms and motor and speech disorders may occur. Whether everolimus exacerbates the neurotoxicity of CsA is not known. We describe a patient who developed severe neurologic complications, consistent with CsA-induced neurotoxicity, developing 7.5 years after cardiac transplantation, 3 months after everolimus was added to the immunosuppressive regimen.

Etiology of anemia in patients with advanced heart failure.

OBJECTIVES: We prospectively investigated the causes of anemia in patients with advanced congestive heart failure (CHF). BACKGROUND: Anemia is common in patients with advanced CHF, and its etiology is generally considered to be multifactorial. However, despite its importance, precise information is lacking regarding the prevalence of putative etiologic factors. METHODS: Patients who were hospitalized for decompensated advanced CHF and who were stabilized after their initial treatment underwent evaluation of "clinically significant" anemia, defined as a hemoglobin content <12 g/dl for men and <11.5 g/dl for women. Patients with a serum creatinine concentration >3 mg/dl or patients with concurrent diseases that are known to cause anemia were not included. The initial evaluation included measurements of vitamin B(12), folic acid, thyroid-stimulating hormone, erythropoietin, lactate dehydrogenase, Coombs test, multiple fecal occult tests, and bone marrow aspiration. Patients without diagnosis by these methods underwent red cell mass measurement with (51)Cr assay. RESULTS: The mean age of the 37 patients was 57.9 +/- 10.9 years and mean left ventricular ejection fraction 22.5 +/- 5.9%. Iron deficiency anemia was confirmed by bone marrow aspiration in 27 patients (73%), 2 patients (5.4%) had dilutional anemia, and 1 patient (2.7%) had drug-induced anemia. No specific cause was identified in 7 patients (18.9%) who were considered to have "anemia of chronic disease." Serum ferritin for the iron-deficient patients was not a reliable marker of iron deficiency in this population. CONCLUSIONS: In this group of patients, iron deficiency was the most common cause of anemia. The iron status of patients with end-stage chronic CHF should be thoroughly evaluated and corrected before considering other therapeutic interventions.

Cardiogenic shock due to isolated right ventricular infarction in an elderly woman.

A 78-year-old hypertensive woman with no prior history of ischemic heart disease arrived at the hospital complaining of weakness and profound fatigue. Four days earlier, she had experienced substernal chest pain associated with nausea and vomiting. A standard 12-lead electrocardiogram showed marked ST-segment elevation and negative T waves in leads V1 and V2. The patient was treated with anti-thrombotic therapy, dobutamine and dopamine infusions. Angiography showed proximal occlusion of a small, non-dominant right coronary artery and no clinically significant disease in the left coronary artery. Isolated right ventricular infarction accounted for the cardiogenic shock in this elderly patient. She received conservative medical treatment and was discharged in good condition.

Prevalence and prognostic significance of anemia in patients with congestive heart failure treated with standard vs high doses of enalapril.

BACKGROUND: Anemia is common in patients with congestive heart failure (CHF), although its etiology and pathophysiology remain largely unexplained. The purpose of this study was to examine the prognostic significance of a low hematocrit (Hct) in patients with CHF and the possible role of angiotensin-converting enzyme inhibition in anemia development. METHODS: Hct was measured at the time of enrollment of 160 patients with CHF, mean age 56 +/- 12 years, in New York Heart Association (NYHA) functional class 2.6 +/- 0.7 and with left ventricular ejection fraction of 20 +/- 9%. They were randomized to standard (mean: 17.9 +/- 4.3 mg/day) or high (mean: 42 +/- 19.3 mg/day) doses of enalapril. The follow-up duration was 2 years. Cox regression models were used to identify prognostic factors, and correlations among individual variables were tested. RESULTS: Mean baseline Hct was 42.7 +/- 5%. In multivariate analyses, low Hct (p = 0.036), older age (p = 0.022) and low systolic blood pressure (p = 0.032) were independent predictors of death within 2 years. A correlation was found between baseline Hct and NYHA class (Spearman's correlation coefficient: -0.183, p = 0.008). A significant decrease in Hct from 43.2 +/- 4.9% at baseline to 40.7 +/- 4.4% at 2 years was observed in the group treated with high doses of enalapril (p < 0.001). CONCLUSIONS: Low baseline Hct predicted poor 2-year prognosis in patients with CHF. Enalapril administered in high doses increased the incidence of anemia in this population. The underlying pathophysiologic mechanism and effects of maintaining a normal Hct on clinical outcomes remain to be determined.

Resuscitation from adrenaline resistant electro-mechanical dissociation facilitated by levosimendan in a young man with idiopathic dilated cardiomyopathy.

A 32-year-old man with severe congestive heart failure due to idiopathic cardiomyopathy developed ventricular tachycardia followed by electro-mechanical dissociation. High doses of conventional inotropic medications failed to restore haemodynamics. The additional infusion of levosimendan in conjunction with external chest compressions for 2.5 h restored haemodynamics, followed by complete recovery, including normal neurological function. The anti-stunning properties of levosimendan probably attenuated post-ischaemic myocardial dysfunction and helped to restore normal cardiac output.

The long-term survival benefit conferred by intermittent dobutamine infusions and oral amiodarone is greater in patients with idiopathic dilated cardiomyopathy than with ischemic heart disease.

BACKGROUND: Intermittent dobutamine infusions (IDI) combined with oral amiodarone improve the survival of patients with end-stage congestive heart failure (CHF). The purpose of the present study was to evaluate whether the response to long-term treatment with IDI+amiodarone is different in patients with ischemic heart disease (IHD) versus idiopathic dilated cardiomyopathy (IDC). METHODS: The prospective study population consisted of 21 patients with IHD (the IHD Group) and 16 patients with IDC (the IDC Group) who presented with decompensated CHF despite optimal medical therapy, and were successfully weaned from an initial 72-h infusion of dobutamine. They were placed on a regimen of oral amiodarone, 400 mg/day and weekly IDI, 10 microg/kg/min, for 8 h. RESULTS: There were no differences in baseline clinical and hemodynamic characteristics between the 2 groups. The probability of 2-year survival was 44% in the IDC Group versus 5% in the IHD Group (long-rank, P=0.004). Patients with IDC had a 77% relative risk reduction in death from all causes compared to patients with IHD (odd ratio 0.27, 95% confidence interval 0.13 to 0.70, P=0.007). In contrast, no underlying disease-related difference in outcomes was observed in a retrospectively analyzed historical Comparison Group of 29 patients with end stage CHF treated by standard methods. CONCLUSIONS: Patients with end stage CHF due to IDC derived a greater survival benefit from IDI and oral amiodarone than patients with IHD.