Sodium nitroprusside for advanced heart failure. A metanalysis of literature data.

Advanced heart failure (HF) is associated with a very poor prognosis and places a big burden on health-care services. The gold standard treatment, i.e. long-term mechanical circulatory support or heart transplantation, is precluded in many patients but observational studies suggest that the use of SNP might be associated with favourable long-term clinical outcomes. We performed a metanalysis of published studies that compared sodium nitroprusside (SNP) with optimal medical therapy to examine the safety and efficacy of SNP as part of the treatment regimen of patients hospitalized for advanced heart failure (HF). We searched PUBMED, EMBASE and WEB OF SCIENCE for studies that compared SNP with optimal medical therapy in advanced HF on July 2022. After screening 700 full-text articles, data from two original articles were included in a combined analysis. The analysis demonstrated a 66% reduction in the odds of death in advanced HF patients treated with SNP. The results show the potential importance of the inclusion of SNP in the treatment regimen of patients hospitalized because of advanced HF and underlines that controlled, randomized studies are still required in this condition.

Additional predictive value of nutritional status in the prognostic assessment of heart failure patients.

BACKGROUND AND AIMS: Nutritional status (NS) is not routinely assessed in HF. We sought to evaluate whether NS may be additive to a comprehensive pre-discharge evaluation based on a clinical score that includes BMI (MAGGIC) and on an index of functional capacity (six minute walking test, 6mWT) in HF patients. METHODS AND RESULTS: The CONUT (Controlling Nutritional Status) score (including serum albumin level, total cholesterol and lymphocyte count) was computed in 466 consecutive patients (mean age 61 ± 11 years, NYHA class 2.6 ± 0.6, LVEF 34 ± 11%, BMI 27.2 ± 4.5) who had pre-discharge MAGGIC and 6MWT. The endpoint was all-cause mortality. Mild or moderate undernourishment was present in 54% of patients with no differences across BMI strata. The 12-month event rate was 7.7%. Deceased patients had a more compromised NS (CONUT 2.8 ± 1.5 vs 1.7 ± 1.3, p < 0.0001), and a more advanced HF (MAGGIC 28.2 ± 6.0 vs 22.0 ± 6.6, p < 0.0001; 6MWT 311.1 ± 102.2 vs. 408.9 ± 95.9 m, p < 0.0001). The 12-month mortality rate varied from 4% for well-nourished to 11% for undernourished patients (p = 0.008). At univariate analysis, the CONUT was predictive for all-cause mortality with a Hazard Ratio of 1.701 [95% CI 1.363-2.122], p < 0.0001. Multivariable analysis showed that the CONUT significantly added to the combination of MAGGIC and 6MWT and improved predictive discrimination and risk classification (c-index 0.82 [95% CI 0.75-0.88], integrated discrimination improvement 0.028 [95% CI 0.015-0.081]). CONCLUSIONS: In HF patients assessment of NS, significantly improves prediction of 12-month mortality on top of the information provided by clinical evaluation and functional capacity and should be incorporated in the overall assessment of HF patients.

Visualization of left atrial appendage and assessment of its function by transthoracic second harmonic imaging and contrast-enhanced pulsed Doppler.

BACKGROUND: Low flow velocity within the left atrial appendage, as assessed by transoesophageal echocardiography, is a predictor of thromboembolism and of a low success rate of cardioversion of atrial fibrillation. However, the semi-invasive nature does limit its serial application as a screening technique. METHODS AND RESULTS: We investigated the value of transthoracic second harmonic echocardiography and pulsed Doppler at baseline and after intravenous contrast injection to visualize the left atrial appendage and assess blood flow velocities within its cavity. We studied 51 consecutive patients undergoing transoesophageal echocardiography. After transoesophageal echocardiography, transthoracic second harmonic imaging was performed and the left atrial appendage was visualized in 46 patients. Interpretable pulsed Doppler tracings of left atrial appendage flow were obtained at baseline in 39 patients and in 45 patients during Levovist administration. The correlations between peak emptying velocity of left atrial appendage as measured by transoesophageal echocardiography and by transthoracic standard and contrast-enhanced Doppler were 0.81 and 0.91, respectively. The agreement between transoesophageal echocardiography and transthoracic contrast-enhanced pulsed Doppler echocardiography in classifying left atrial appendage flow velocity patterns was 93%. Left atrial appendage thrombus was detected by transthoracic second harmonic imaging in only one of the eight patients shown by transoesophageal echocardiography to have a thrombus. However, all but one of the patients with left atrial appendage thrombus and/or spontaneous echocardiographic contrast at transoesophageal echocardiography had <30cm/s left atrial appendage flow velocity by transthoracic Doppler. CONCLUSIONS: This study shows that left atrial appendage can be visualized by transthoracic second harmonic imaging and that the flow velocity within its cavity is reliably measured by pulsed Doppler in a substantial fraction of patients. Contrast enhancement improves the feasibility and the accuracy of transthoracic evaluation of left atrial appendage flow velocity. The practical value of these results in predicting thromboembolic risk and success of cardioversion of atrial fibrillation needs to be proved by prospective studies.

Doppler echocardiography reliably predicts pulmonary artery wedge pressure in patients with chronic heart failure even when atrial fibrillation is present.

BACKGROUND AND AIMS: In patients with chronic congestive heart failure a high pulmonary artery wedge pressure (PAWP) is associated with poor prognosis, severe symptoms and low exercise tolerance. When atrial fibrillation is present the non-invasive prediction of PAWP by Doppler echocardiography is generally considered to be not reliable. METHODS: In 51 consecutive patients with chronic heart failure, due to either ischemic and non-ischemic dilated cardiomyopathy, and atrial fibrillation simultaneous Doppler echocardiographic and hemodynamic studies were used to estimate PAWP. The power of the obtained multivariate equation was compared with that of previously developed equations and was then prospectively tested in a group of 15 patients. RESULTS: The deceleration rate (DR) of early diastolic mitral flow, the left ventricular iso-volumic relaxation time (IVRT) and the systolic fraction of pulmonary venous flow (SF) were independent predictors of PAWP and the following multivariable equation was derived: PAWP=24.04 + 1.23 x DR- 0.089 x IVRT - 0.175 x SF. The correlation between invasive PAWP and the PAWP non-invasively estimated by this equation in the testing group was 0.91 (standard error of estimate=3.2 mmHg). The mean difference was 0.93 and the standard error of differences was 2.7 mmHg. CONCLUSION: In patients with chronic heart failure due to dilated cardiomyopathy who are in atrial fibrillation a relatively accurate estimation of PAWP can be obtained by Doppler echocardiography of mitral and pulmonary venous flow.

[Non-invasive evaluation of the hemodynamic profile in patients with heart failure: estimation of cardiac output]. / Valutazione non invasiva del profilo emodinamico nel paziente con scompenso cardiaco: stima della portata cardiaca.

In patients with chronic heart failure the estimation of cardiac output represents a valuable tool in assessing both prognosis and therapy. The thermodilution method during right heart catheterization remains the standard method, even if some echo-Doppler methods have been demonstrated to be feasible and accurate in determining cardiac output. Using echo-Doppler it is also possible to determine right atrial pressure (evaluating respiratory changes in the diameter of the inferior vena cava), the right ventricular-atrial pressure gradient (using the continuous wave Doppler of the tricuspid regurgitant jet) and, consequently, systolic pulmonary artery pressure. Diastolic pulmonary artery pressure can be calculated from the continuous wave Doppler of the pulmonary regurgitant jet, so mean pulmonary artery pressure can be calculated. Pulmonary capillary wedge pressure can be calculated by echo-Doppler using a few methods proposed in the literature. All these parameters allow for the calculation of the transpulmonary gradient and (with determination of cardiac output) of pulmonary vascular resistance. The main purpose is the assessment of prognosis after heart transplantation. Due to the fact that chronic heart failure patients need serial evaluations when awaiting for transplantation, echocardiography could became an alternative, safe and feasible procedure in these cases.

Orthotopic heart transplantation: standard versus bicaval technique.

We compared orthotopic heart transplantation (HT) by bicaval technique with the standard technique. Between January 1995 and December 1997, 117 patients underwent 118 HTs; 71 patients (15 women and 56 men) had 72 HTs by standard technique and 46 patients (9 women, 37 men) underwent HT using bicaval procedures. Preoperative parameters were similar in both groups; 5 patients who underwent the standard technique and no patients who underwent bicaval procedures required permanent pacemakers (p = NS). Isoproterenol infusion was significantly longer in the standard technique. Major perioperative arrhythmias (ventricular tachycardia and fibrillation, asystole) appeared in 8.2% and 7.0% of standard and bicaval HTs, respectively; atrial fibrillation appeared in 13.1% and 4.6%, respectively (p = NS). At 1 month, mitral and tricuspid regurgitation rates were higher in the standard group (p = NS); at 1 year only tricuspid regurgitation was still higher (p = NS). Right atrial pressure, Wood units, cardiac output, and cardiac index were examined (p = NS). At multivariate analysis, interaction between preoperative Wood units and transplant type was elicited for Wood units at 1 month and for right atrial pressure at 1, 3, and 6 months. In the high resistance subgroup, the patients who underwent bicaval procedures had higher resistances at 1 month. In the low resistance subgroup, right atrial pressure was higher in patients who underwent standard techniques at 1, 3, and 6 months follow-up. Thus, bicaval HT was found to be safe, without surgically related complications, it provoked significantly less blood loss, and required less isoproterenol use. No significant advantages were observed in conduction disturbances and major arrhythmias or regarding the need for temporary or permanent pacemakers.

Dobutamine stress echocardiography and thallium-201 SPECT for detecting ischaemic dilated cardiomyopathy in patients with heart failure.

AIMS: A diagnosis of ischaemic aetiology of a dilated cardiomyopathy has important therapeutic and prognostic implications. In such patients, abnormal ECG and atypical symptoms limit the usefulness of standard ECG-ergometry in detecting myocardial ischaemia. To assess the values of high-dose dobutamine stress echocardiography and of Thallium-201 SPECT (exercise-reinjection-rest protocol) in differentiating between ischaemic and non-ischaemic dilated cardiomyopathy, 37 patients with suspected myocardial ischemia, low ventricular ejection fraction (23 +/- 5%) and heart failure were studied. METHODS AND RESULTS: Coronary artery disease was defined as >50% coronary stenosis in at least one coronary artery. By dobutamine stress echocardiography, ischaemic dilated cardiomyopathy was considered present when either an ischaemic response (biphasic response or direct deterioration) or a scar (fixed dyssynergy) was documented in at least two segments. By Thallium-201 SPECT, severe perfusion defects, either reversible (ischaemia) or fixed (scar), in at least two segments were considered markers of ischaemic dilated cardiomyopathy. Twenty-three patients had ischaemic dilated cardiomyopathy, while 14 had normal coronary arteries. The presence of myocardial ischaemia and/or scar by dobutamine stress echocardiography identified patients with ischaemic dilated cardiomyopathy with a sensitivity of 100% and a specificity of 86%. The sensitivity of Thallium-201 SPECT was 92%, its specificity was 69%. Three of the four false positive results occurred in patients with left bundle branch block. Thirty-two patients were concordantly classified by the two techniques (agreement=86%, k=0.73). CONCLUSION: Both dobutamine stress echocardiography and Thallium-201 SPECT are sensitive techniques for detecting the ischaemic aetiology of dilated cardiomyopathy. The specificity is lower, particularly by SPECT, when left ventricular branch block is present.

Identification of chronic heart failure patients at risk of Cheyne-Stokes respiration.

Chronic heart failure (CHF) patients frequently show sleep-disordered breathing consisting of periodic breathing (PB) and Cheyne-Stokes respiration (CSR) with central sleep apnoea (CSA). Since the diagnosis of sleep-disordered breathing, in CHF patients, can be made only by means of full polysomnography, the aim of the present study was to evaluate whether or not daytime respiratory function can identify patients at risk of nocturnal PB and/or CSR/CSA. Twenty-seven patients (mean age 54 +/- 8.5 yrs), eight New York Heart Association Functional Class (NYHAFC) II, 17 NYHAFC III and two NYHAFC IV, with severe cardiac failure (cardiac output 2.0 +/- 0.66 L.min-1, ejection fraction 22.5 +/- 5.77%, pulmonary capillary wedge/pressure 23 +/- 9.05 mmHg). Mouth occlusion pressure (P0.1)/maximal inspiratory pressure (MIP) was significantly higher in patients with nocturnal CSR/CSA (5.04 +/- 1.49 versus 3.24 +/- 2.13%, analysis of variance (ANOVA) 0.03), whereas their arterial carbon dioxide tension (Pa,CO2) was significantly lower (4.15 +/- 0.56 (31.2 +/- 4.23 mmHg) versus 4.67 +/- 0.53 kPa (35.1 +/- 4 mmHg), ANOVA 0.02). Logistic regression analysis demonstrated that CSR/CSA occurrence may be predicted by daytime measurement of P0.1/MIP and Pa,CO2 (p = 0.04 and 0.01 respectively; odds ratio 1.93 and 0.76 respectively). The sensitivity was 70%, specificity 76.5%, false positive rate 36.4%, false negative rate 18.8%, positive predictive value 71.4% and negative predictive value 85%. This model seems useful for predicting respiratory pattern changes in chronic heart failure patients and the authors suggest that polysomnography be performed only in high-risk patients, saving costs and the resources of sleep laboratories.

The bicaval anastomosis technique for orthotopic heart transplantation yields better atrial function than the standard technique: an echocardiographic automatic boundary detection study.

BACKGROUND: Atrial function is an important determinant of cardiac performance. In patients who undergo operation by standard heart transplantation atrial enlargement, distortion of geometry and asynchronous contraction resulting from the donor/recipient atrial connections may affect atrial function. The bicaval anastomosis technique should be free from these limitations. METHODS: We used the echocardiographic automatic boundary detection technique to obtain on-line time/volume curves of right and left atria from patients who had undergone bicaval (n = 22) or standard (n = 27) heart transplantation and from 15 control subjects. Maximal, middiastolic, preatrial contraction, and minimal volumes of both atria were measured. Reservoir volume (defined as the difference between maximal and middiastolic atrial volumes); pump volume (defined as the difference between preatrial contraction and minimal atrial volumes); and conduit volume (defined as the difference between left ventricular stroke volume and the sum of reservoir and pump volumes) were derived for both atria. Atrial emptying fraction was calculated as the difference between maximal and minimal volumes divided by the maximal volume and expressed in percent and pump fraction as the pump volume divided by the sum of reservoir and pump volumes. Tricuspid and mitral regurgitation, evaluated by color-flow Doppler scanning, were considered significant when they were greater than grade 1. Atrial ejection force was calculated from mitral and tricuspid flow velocities at atrial contraction. RESULTS: In patients who had bicaval heart transplantation, both atria were smaller than in patients who underwent standard heart transplantation. With the bicaval technique right and left atrial emptying (right 45% +/- 9% vs 36% +/- 10%, p < .05; left 51% +/- 8% vs 39% +/- 8%, p < .001) and pump fractions (right 57% +/- 17% vs 19% +/- 13%, p < .001; left 45% +/- 28% vs 22% +/- 12%, p < .01) were greater than with the standard technique and similar to those in control subjects. Right atrial ejection force was significantly greater in bicaval (10.0 +/- 5.6 kdyne) than in standard heart transplantation (4.5 +/- 2.2 kdyne, p < .0001). Significant tricuspid or mitral regurgitation was rarely found in bicaval heart transplant recipients (3 and 1 of the 22 patients, respectively), although they were much more frequent after standard heart transplantation (13 and 8 of the 27 patients, respectively). CONCLUSIONS: Heart transplantation performed with the bicaval anastomosis technique determines smaller atrial volumes, yields better right and left atrial function and fewer atrioventricular valve regurgitation than the standard technique.

Predictors of primary atrial fibrillation and concomitant clinical and hemodynamic changes in patients with chronic heart failure: a prospective study in 344 patients with baseline sinus rhythm.

OBJECTIVES: This study investigated the incidence, predisposing factors and significance of the onset of atrial fibrillation (AF) in patients with chronic congestive heart failure (CHF). BACKGROUND: The association between CHF and AF is well documented, but the factors that predispose to the onset of the arrhythmia and its impact remain controversial. Methods. We prospectively followed up 344 patients with CHF and sinus rhythm (SR). Over a period of 19 +/- 12 months (mean +/- SD), 28 patients developed atrial fibrillation (AF), which became chronic in 18. RESULTS: At baseline, no differences were found in any clinical and hemodynamic variables between patients who developed chronic AF and those who did not. Reversible AF occurring during follow-up and lower mitral flow velocity at atrial contraction as detected at the last evaluation in SR were independent predictors of the subsequent development of chronic AF. When AF occurred, New York Heart Association functional class worsened (from 2.4 +/- 0.5 to 2.9 +/- 0.6, p = 0.0001), peak exercise oxygen consumption declined (from 16 +/- 5 to 11 +/- 5 ml/kg per min, p = 0.002), cardiac index decreased (from 2.2 +/- 0.4 to 1.8 +/- 0.4, p = 0.0008), and mitral and tricuspid regurgitation increased (from grade 1.8 +/- 1.1 to grade 2.4 +/- 1.4, p = 0.0001 and from grade 1.0 +/- 1.2 to grade 1.8 +/- 1.2, p = 0.001, respectively). Systemic thromboembolism occurred in 3 of the 18 patients with AF. Nine of 18 patients died after AF, and the occurrence of AF was a predictor of major cardiac events. CONCLUSIONS: In patients with CHF, reversible AF and reduction of left atrial contribution to left ventricular filling predict the subsequent development of chronic AF. The onset of AF is associated with clinical and hemodynamic deterioration and may predispose to systemic thromboembolism and poorer prognosis.

Sleep disorders and breathing alterations in patients with chronic heart failure.

Cheyne-Stokes respiration can appear during sleep in patients with chronic heart failure and is generally attributed to a tendency to hyperventilate causing PCO2 to fall below the apnea threshold. We recorded sleep pattern and nocturnal arterial oxygen desaturation during Cheyne-Stokes respiration and correlated those with hemodynamic alterations, in order to investigate their possible role in the evolution of chronic heart failure. Sixty chronic heart failure patients, after optimization of therapy, underwent a polysomnographic study and hemodynamic and echocardiographic evaluations within a few days. The patients were then enrolled in the follow-up of our pre-transplantation program. Only slight alterations of sleep architecture were detected. During sleep, Cheyne-Stoke respiration was present in 50% and arterial oxygen desaturations in 54% of patients. An increased pulmonary wedge pressure (24.7 +/- 8.3 vs 16.7 +/- 8.9 mmHg, p < 0.000) was significantly correlated with the presence of nocturnal Cheyne-Stokes episodes, while cardiac index was not (1.9 +/- 0.6 vs 2.0 +/- 0.5 l m-2 min-1, p = 0.42). In a multivariate analysis of hemodynamic and polysomnographic data, mortality or heart transplantation in status 1 was predicted at the two year follow-up only by an increased pulmonary wedge pressure. In conclusion, in advanced chronic heart failure, with optimized therapy, nocturnal Cheyne-Stokes respiration is present in half of the cases, with concomitant falls in arterial oxygen desaturation. These events were not independently predictive of mortality. The strong correlation found between increased left ventricular filling pressure and presence of Cheyne Stokes respiration and the lack of correlation with cardiac index suggest that other hemodynamic mechanisms besides reduced cardiac output are responsible for this respiratory abnormality.

Loading manipulations improve the prognostic value of Doppler evaluation of mitral flow in patients with chronic heart failure.

BACKGROUND: Mitral flow velocity patterns (MFVPs) evaluated by Doppler echocardiography are strong predictors of survival in various cardiac diseases. However, MFVPs may change over time according to loading conditions. We performed this prospective study to assess whether changes in MFVP induced by loading manipulations provided additional prognostic information in 173 patients with chronic heart failure. METHODS AND RESULTS: Simultaneous Doppler echocardiographic and right-sided hemodynamic recordings were obtained at baseline in all patients, during nitroprusside infusion in the 98 patients who had a baseline restrictive (early-to-late flow velocity ratio > 1 and deceleration time < or = 130 ms) MFVP, and during passive leg lifting in the 75 patients who had a baseline nonrestrictive MFVP. Patients were categorized, according to changes in MFVP, into four groups: 61 patients with an irreversible restrictive, 37 with a reversible restrictive, 48 patients with a stable nonrestrictive, and 27 patients with an unstable nonrestrictive MFVP. Fifty patients experienced major cardiac events. Cox analysis revealed that MFVP was a strong predictor of events and that the response to loading manipulations improved its prognostic value. Patients with an irreversible restrictive MFVP had a higher event rate (51%) than patients with a reversible restrictive MFVP (19%). Among patients with a baseline nonrestrictive MFVP, those with a stable nonrestrictive MFVP had the lowest event rate (6%), whereas the event rate was 33% in patients with an unstable nonrestrictive MFVP. CONCLUSIONS: In patients with chronic heart failure, MFVPs provide independent prognostic information. Their prognostic value can be further increased by assessment of the changes induced in them by loading manipulations.

Assessment of right ventricular function in patients with congestive heart failure by echocardiographic automated boundary detection.

In patients with chronic heart failure, echocardiographic automated boundary detection (ABD) can reliably assess right ventricular function. The measurements obtained by ABD were highly reproducible, strongly correlated with radionuclide right ventricular ejection fraction, and superior to those obtained by conventional manual echocardiographic methods.

Mitral flow velocity changes after 6 months of optimized therapy provide important hemodynamic and prognostic information in patients with chronic heart failure.

Transmitral flow velocity patterns evaluated by Doppler echocardiography provide important hemodynamic and prognostic information in various cardiac conditions. However, these patterns may change over time, and so far the hemodynamic and prognostic significance of these changes has not been established. Accordingly, we performed this study to determine the hemodynamic and prognostic value of changes in transmitral flow velocity patterns after 6 months of optimized medical treatment in patients with chronic heart failure due to ischemic or nonischemic dilated cardiomyopathy. Ninety-eight consecutive patients with chronic heart failure underwent a clinical examination, a cardiopulmonary exercise test, and simultaneous Doppler echocardiographic and hemodynamic studies at baseline and after 6 months, patients were followed up for 12 +/- 7 months. Cardiac death and heart transplantation while patients were in critical condition were considered events. A restrictive pattern was defined by an early-to-late peak diastolic velocity ratio > 1 and an early diastolic deceleration time < or = 130 msec. Patients were grouped according to their mitral flow pattern at baseline and its changes after chronic optimized therapy. No significant changes in clinical, ergometric, and hemodynamic variables were found after 6 months in the 49 patients who had a persistent restrictive transmitral flow pattern or the 24 patients who had a persistent nonrestrictive transmitral flow pattern. In the 19 patients who had a restrictive pattern at baseline that reverted into a nonrestrictive pattern, this change was accompanied by a highly significant reduction in pulmonary wedge pressure (from 25 +/- 7 mm Hg to 11 +/- 3 mm Hg) and by an increase in exercise capacity, whereas in the 6 patients who had a nonrestrictive pattern that became restrictive, hemodynamic features markedly deteriorated. Seventeen of the 21 events occurred in the 49 patients (event rate 35%) with a persistent restrictive pattern, whereas the event rate was much lower in the 19 patients with a reversible restrictive pattern (5%) and in the 24 patients with a persistent nonrestrictive pattern (4%). Two (33%) of the 6 patients in whom a restrictive pattern developed had events. Cox analysis revealed that a restrictive transmitral flow pattern (p = 0.0068) and peak rate of oxygen consumption (p = 0.0056) detected at the late examination were significantly related to cardiac events. These results show that in patients with chronic heart failure, changes in transmitral flow patterns after chronic optimized therapy are correlated with changes in pulmonary wedge pressure, are accompanied by changes in functional capacity, and provide relevant independent prognostic information.

Comparison of Doppler echocardiography with thermodilution for assessing cardiac output in advanced congestive heart failure.

Noninvasive cardiac output estimation by Doppler echocardiography was compared with thermodilution and Fick oxygen methods in 73 patients with advanced chronic congestive heart failure due to dilated cardiomyopathy. In these patients, Doppler echocardiographic measurements showed a closer agreement with Fick measurements than that of thermodilution.

Concomitant factors of decompensation in chronic heart failure.

The concomitant factors implicated in 328 nonfatal decompensations of 304 patients with congestive heart failure were: arrhythmias in 24%, infections in 23%, poor compliance in 15%, angina in 14%, iatrogenic factors in 10%, and other causes in 5% of cases. New York Heart Association class and right atrial pressure significantly related to the occurrence of decompensation. Poor compliance and angina were unpredictable, infection was related to pulmonary wedge pressure, iatrogenic factors were predicted by the more advanced functional classes, whereas arrhythmias were more frequent in patients with renal failure.

[Heart failure unit: 1 year experience]. / Unità per lo scompenso cardiaco: un anno di esperienza.

Many factors such as aging and pharmacologic and surgical progress contribute to the growing of organizational problems of health care for patients with severe chronic heart failure. Since March 16, 1992, in the Medical Center of Montescano, an experimental model (Heart Failure Unit) of health assistance has been in development, taking into account the assistance and observational needs of such patients. During the first year of activity, 173 patients were treated in the Unit, for a total of 307 admissions. In-hospital complications were 5 deaths, 91 severe heart decompensations, 25 severe ventricular tachyarrhythmias, 17 infections, 11 severe bradyarrhythmias, 6 instances of acute heart failure due to atrial arrhythmias, 5 unstable angina episodes, 3 thromboembolisms, and 3 neuropsychiatric disorders. During the follow-up until August 15, 1993, 27 patients died and 19 underwent heart transplantation. Our experience focused on realizing the following goals: 1) to organize a fit hospital environment and adequate nursing; 2) to pursue the autonomy and independence of the patients; 3) to routinely cooperate in a multidisciplinary team; 4) to offer continuity of care to patients.

[Skeletal and respiratory muscle strength in chronic heart failure]. / Forze dei muscoli scheletrici e respiratori nello scompenso cardiaco cronico.

BACKGROUND: The aim of this study was to investigate limb and respiratory muscle strength in chronic heart failure (CHF). METHODS: Our study population consisted of 45 male CHF patients, 25 in NYHA Class II and 20 in NYHA Class III, and 22 male post-MI patients without left ventricular dysfunction (LVEF > 50%). All patients underwent assessment of respiratory muscle strength by maximal inspiratory (MIP) and expiratory (MEP) pressures, of handgrip force and peak torque developed during isokinetic Knee extension (EX) (quadriceps) and flexion (hamstring) at 120 degrees/sec. RESULTS: CHF patients showed a significant decrease in all limb and respiratory muscle strength compared to control patients. Moreover, NYHA Class III patients showed significantly reduced values of MIP, handgrip, and EX forces, as well as significantly reduced exercise tolerance in terms of METS (2.8 +/- 0.9 vs 4.4 +/- 1.2, p < .05) and anaerobic threshold level (9.4 +/- 3 vs 12.8 +/- 1.7 mlO2/Kg, p < .05), as compared to those patients in NYHA Class II, while no significant differences were observed in LVEF, cardiac index and pulmonary capillary wedge pressures. Weak, but significant (p < .05) were the correlations between limb muscle and respiratory muscle strength. No correlations were found between muscle force and hemodynamic parameters. Significant correlations (from p < .05 to p < .0001) were found among exercise tolerance and limb muscle strength, but not between exercise tolerance and respiratory muscle strength. In summary: 1) respiratory and skeletal muscle strength is impaired in CHF; 2) respiratory and limb muscle strength reductions are partially related to each other; 3) the degree of central hemodynamic impairment is not correlated with muscle force. Deconditioning could be a major determinant of skeletal but not respiratory muscle weakness. Other factors link limb and respiratory weakness in CHF.