History Of CHF Research Articles

Predictors of cardiovascular events in patients with type 2 diabetic nephropathy and hypertension: A case for albuminuria

Individuals with type 2 diabetes and nephropathy represent a particularly high-risk group for both adverse cardiac as well as renal events. Using the Irbesartan in Diabetic Nephropathy Trial (IDNT) cohort, our objective was to determine baseline characteristics of individuals with type 2 diabetic nephropathy and hypertension predictive for cardiac events. IDNT identified 1715 individuals with type 2 diabetic nephropathy and hypertension having serum creatinine of 1.0 to 3.0 mg/dL and urinary albumin excretion rates > or = 900 mg/day. A cardiovascular (CV) composite was used consisting of CV death, nonfatal MI, hospitalization for heart failure, stroke, amputation, and coronary and peripheral revascularization. Using multivariable Cox regression analysis, 41 baseline characteristics determined a priori were analyzed for their potential relationship to risk of experiencing a CV event. Of the 1715 individuals, 518 (30.2%) had at least one of the CV composite end points. Older age, male gender, longer duration of diabetes, history of cardiovascular disease, history of CHF, high urinary albumin:creatinine ratio, and low serum albumin were strong predictors for CV events; of these, prior history of CVD (RR 2.00, 95% CI 1.63-2.45; P < 0.0001) and high urinary albumin:creatinine ratio (RR 1.29 per natural log unit, 95% CI 1.13-1.48; P = 0.0002) at baseline were highly predictive for cardiovascular events. In conclusion, among individuals with hypertension and diabetic nephropathy, both the degree of albuminuria and lower serum albumin levels provide additional prognostic information concerning cardiovascular risk, in addition to traditional coronary risk factors.

Creatinine clearance but not serum creatinine alone predicts long-term postoperative survival

Abstract Introduction: End-stage renal disease is a risk factor for perioperative morbidity and shortened survival after major surgery. Given the multiple confounding factors related to serum creatinine, we aimed to determine if estimated creatinine clearance more accurately predicts long-term survival. Methods: We retrospectively reviewed the vascular registry at our institution. Logistic regression analysis was conducted to determine independent predictors of one-, two-, and three-year mortality. Creatinine clearance was calculated as [[140-age(yr)]∗weight(kg)]/[72∗serum Cr(mg/dL)] (multiplied by 0.85 for women). Results: 252 patients underwent infrainguinal bypass procedures between August 1999 and May 2000. Demographics included average age 68 years, 65% male, 74% diabetic, 12% dialysis-dependent, 23% history of CHF, 12% history of stroke, and 20% serum creatinine >2mg/dL. One-, two-, and three-year mortalities were 16%, 25%, and 35%, respectively. Creatinine did not differ between survivors and non-survivors at one year (1.8 vs 1.9, p=0.802), two years (1.8 vs 2.0, p=0.618), or three years (1.8 vs 2.0, p=0.241), and creatinine >2mg/dL did not predict long-term adverse outcomes. In contrast, reduced creatinine clearance (60 ml/min) was an independent predictor of mortality regardless of dialysis statis (1-yr: OR=2.53, p=0.014; 2-yrs: OR=2.46, p=0.004; 3-yrs: OR=2.45, p=0.001), and creatinine clearance was higher for survivors at all three time points (1-yr: 70.2 vs 49.5, p=0.003; 2-yrs: 72.3 vs 51.2, p Conclusions: Regardless of dialysis status, a decreased creatinine clearance, but not elevated creatinine alone, is an independent predictor of postoperative mortality. This measure should be included in preoperative risk evaluations of patients undergoing major surgical procedures.

The incidence of congestive heart failure associated with antidiabetic therapies.

Increased risk for CHF in persons with type 2 diabetes is well established. Our objectives were to estimate the CHF risk associated with specific therapies for diabetes and to determine the differences in incidence rates of CHF associated with adding various antidiabetic agents. Subjects were members of the Kaiser Permanente Northwest (KPNW) diabetes registry as of 1 January 1998, with no prior history of CHF (n = 8063). We identified their therapy as of that date and then defined the start of the subject study period as the date when their drug regimen changed, either by switching to or by adding another antidiabetic drug. We defined the new therapy as the index therapy and the date of initiating the new therapy as the index date. Follow-up on the patients was done until the index therapy was discontinued or changed, or until 31 December 2002, whichever came earlier. We calculated the incidence rate of CHF in patients on various therapeutic regimens adjusting for age, gender, diabetes duration, existing ischemic heart disease, hypertension, renal insufficiency and glycemic control (HbA(1c)). CHF incidence rates were highest in index therapy categories that included insulin and lowest in regimens that included metformin. When insulin was added to an initial therapy, CHF incidence was increased 2.33 times (p < 0.0001) and 2.66 times (p < 0.0001) compared to the addition of sulphonylurea or metformin respectively. Our findings support the theory that elevated serum insulin levels promote the development of cardiac disease. Consistent with the UKPDS, metformin may offer some protection from incident CHF relative to sulphonylurea or insulin.

Depressive symptoms and mortality two years after coronary artery bypass graft surgery (CABG) in men.

Depression has been related to mortality in patients with CAD and to medical morbidity after CABG; however, prior studies have not examined the contribution of presurgical depressive symptoms to mortality after CABG. The purpose of this study was to determine the independent contribution of presurgical symptoms of depression to 2-year cardiac mortality after CABG. Eighty-nine consecutive veteran nonemergent CABG patients recruited between December 1996 and June 1998 completed the BDI 1 to 7 days before surgery. Mortality risk was assessed by medical co-morbidity and RIS. Significant univariate contributions to two-year cardiovascular mortality were found for RIS (chi2 = 6.57, p <.01), history of CHF (chi2 = 4.94, p <.02), history of COPD (chi2 = 5.19, p <.02), and elevated depressive symptoms (chi2 = 4.70, p <.03). The multivariate model revealed that the RIS (chi2 = 4.70, p <.03) and elevated depressive symptoms (chi2 = 3.86, p <.05) remained significant in the prediction of 2-year cardiovascular mortality, with no other variables being found significant. Elevated depressive symptoms before CABG surgery appear to be an important independent contributor to long-term mortality. Future research should focus on replication with larger, more diverse samples, and identification of pathophysiological mechanisms.

Cardiovascular events in elderly hypertensive patients with osteoarthritis treated with COX-2 specific inhibitors: insights from the success VI and VII trials

The cardiovascular safety profile of the COX-2 specific inhibitors remains unclear. This investigation assessed the long-term outcomes of a pooled cohort of patients enrolled at a single site that participated in two controlled, randomized 6-week trials of rofecoxib and celecoxib that studied 1,092 patients. Fifty-seven patients ≥65 years old with stable, treated hypertension and osteoarthritis received COX-2 specific inhibitors; 3 were lost to follow-up, leaving 54 for further evaluation. At the end of the study, 20 patients continued open-label treatment (15 celecoxib, 6 rofecoxib; 1 patient took both during the period) and 34 discontinued therapy. Patients who continued COX-2 specific inhibitors, compared with those who did not, had a higher incidence of aspirin use (55% vs. 35%), history of angina (40% vs. 35%), and documented coronary artery disease (40% vs. 27%). Fewer patients in the COX-2 specific inhibitor group were male (25% vs. 32%), had diabetes (10% vs. 21%), had a history of CHF (5% vs. 15%), or had a previous MI (5% vs. 24%). One-year telephone follow-up was conducted in all patients, and cardiovascular events (defined as any death, MI, CVA, coronary revascularization, or CHF hospitalization) were assessed (Table). P = not significant P = not significant There was no statistically significant difference in cardiovascular events at 1 year in this high-risk patient cohort between patients receiving or not receiving continuous COX-2 specific inhibitors. However, the small patient population and the important differences in baseline characteristics between the two groups warrant further analysis of the entire randomized patient pool to improve our understanding of the cardiovascular effects of these drugs.

Preoperative Cardiac Evaluation and Interventions Before Aortic Surgery: Are They Justified?

The role of cardiac risk assessment and preoperative cardiac intervention prior to elective vascular surgery remains controversial. In high cardiac risk patients (severe or unstable angina, recent myocardial infarction, decompensated congestive heart failure [CHF]), the risk of an adverse cardiac event is so great that most would agree that these patients should undergo a preoperative cardiac work-up. In most instances strong consideration in these patients should be given to proceeding directly to coronary arteriography In patients with low cardiac risk (those with no active cardiac symptoms, and no Eagle risk factors [angina, age >70 years, history of CHF, Q-wave on EKG, diabetes, ventricular ectopy requiring medication]), the adverse cardiac event rate is so low that one can proceed safely to vascular surgery without any additional cardiac testing. The moderate risk group (patients with one or more Eagle risk factors but without severe or recent cardiac symptoms) may potentially benefit from aggressive...

964-15 Diuretic Therapy Improves Exercise Capacity in Patients with Angina but has no Effect on Nitrate Tolerance

Diuretics have been reported to prevent tolerance to the organic nitrates. Since diuretic therapy itself may have an anti-anginal effect, we carried out a study which examines the effect of diuretic therapy alone on exercise capacity in angina as well as its effect on nitrate tolerance. 12 patients with stable angina were studied. All had normal LV systolic function. None were hypertensive or had a history of CHF. Patients received a diuretic (HCTZ plus amiloride) or placebo for 10–14 days in a randomized, double-blind, cross-over trial. During the last 5–7 days of each treatment period they received continuous transdermal nitroglycerin (TGTN) 0.8 mg/hr in a single blind manner. Treadmill walking time (TWTl was assessed prior to the addition of TGTN (Day 1) to assess the effect of diuretic alone, on the first day of TGTN therapy (Day 2) and on the last day of TGTN therapy (Day 3). Exercise testing was performed at 0800, 1200 and 1600 hrs on each of these days. Diuretic therapy caused an increase in TWT on all 3 study days. HR and systolic BP were higher at peak exercise during diuretic therapy as compared to placebo (data not shown). Diuretic therapy did not prevent the development of tolerance during continuous TGTN therapy.Download : Download high-res image (70KB)Download : Download full-size image*p = &lt; 0.05 vs placebo (cross over analysis of Hills and Armitage). *p = &lt; 0.05 vs placebo (cross over analysis of Hills and Armitage). Diuretic therapy has significant anti-anginal effects and improves exercise capacity in patients with stable angina. Diuretics appear to have no effect on the development of tolerance to continuous TGTN therapy as assessed by treadmill exercise testing.

Exercise Capacity and Prognosis in Patients with Chronic Atrial Fibrillation

To evaluate the response of patients with chronic atrial fibrillation (AF) to exercise and to demonstrate if prognosis could be predicted, 200 male patients (64 +/- 1 years) with AF were identified retrospectively who underwent resting echocardiography and symptom-limited treadmill testing. They were classified by underlying disease into three subgroups: hypertension or no underlying disease (LONE; n = 102), ischemic heart disease (IHD; n = 45) and history of congestive heart failure or valvular disease (CHF-VD; n = 53). Maximal exercise capacities for LONE, IHD and CHF-VD were (mean +/- 1 SEM) 8.0 +/- 0.3, 6.4 +/- 0.4 and 6.0 +/- 0.3 metabolic equivalents, respectively (p < 0.01), and resting left ventricular ejection fractions were 61.7 +/- 1.6, 60.1 +/- 2.2 and 49.5 +/- 1.9%, respectively (p < 0.01). Stepwise multiple regression analysis demonstrated that, except for group classification (R2 = 0.13, p < 0.01), no clinical, exercise or morphologic variables could predict exercise capacity. After a mean 39.1-month follow-up (range 1-78), 17 of the 200 had died from cardiovascular causes. The rate of cardiac death using Kaplan-Meier survival analysis was significantly greater in CHF-VD patients (p < 0.01). However, Cox hazard function and Kaplan-Meier survival analysis demonstrated that neither echocardiographic measurements of cardiac size or function at rest, nor exercise or clinical variables were significant predictors of outcome. AF patients with a history of CHF and/or VD demonstrated a reduced exercise tolerance ad a worse prognosis than those without morphologic heart disease or those with IHD.(ABSTRACT TRUNCATED AT 250 WORDS)