NYHA Functional Class II-IV Research Articles

Role of Empagliflozin in heart failure with severe aortic stenosis before valve replacement: EASTER-HF study

We evaluated empagliflozin in severe DAS patients with HF before AVR. HF patients with LVEF 30–80 % and NYHA functional class II-IV symptoms got empagliflozin 10 mg or not within 6 months before AVR, along with SOC. Adding empagliflozin to the SOC before AVR reduced HF death or HHF by 73 % after 6-months in a group of 20 patients (RR 0.27; p = 0.022). Improving LVEF (+3.48 %, p < 0.001) and NT-proBNP levels (−3974.6 pg/mL) with empagliflozin in SOC before AVR significantly reduced in-hospital and 6-month mortality in this patient group. In severe DAS and HF patients, empagliflozin improved symptoms and prognosis.

A motivational interviewing intervention improves the burden of physical symptoms in patients with heart failure: A secondary outcome analysis of a randomized clinical trial

Abstract Funding Acknowledgements Type of funding sources: Public Institution(s). Main funding source(s): Center of Excellence for Nursing Scholarship, Rome, Italy Background. Patients with heart failure (HF) experience a variety of physical symptoms. Symptoms are perceived by patients as burdensome and, as such, negatively affect quality of life. Besides, physical symptoms are among the first reasons for seeking emergency care and hospitalization. Findings from the MOTIVATE-HF trial show that motivational interviewing (MI) leads to better self-care. However, whether MI also reduces the burden of physical symptoms is not yet known. Purpose. To evaluate the effectiveness of MI on the burden of physical symptoms in patients with HF. Methods. Secondary outcome analysis of the MOTIVATE-HF trial. The study was a three-arm, multicenter randomized controlled trial with a 12-month follow-up. Patients with HF and their informal caregivers were enrolled and randomly divided into three arms: MI performed only with patients (Arm 1); MI performed both with patients and caregivers (Arm 2); usual care (Arm 3). Patients with a diagnosis of HF in NYHA functional class II-IV were recruited in three Italian centers. Participants underwent one face-to-face MI session, followed by three phone calls within two months from enrollment. Physical symptoms were measured with the Heart Failure Somatic Perception Scale (HFSPS) with the dimensions of dyspnea, chest discomfort, early and subtle, and edema. Higher scores at the HFSPS and its dimensions indicate worse physical symptom. Data were collected at baseline, and 3 (T1), 6 (T2), 9 (T3) and 12 (T4) months after enrollment. T-test was used to compare differences in HFSPS scores in Arms 1 and 2 versus Arm 3 at each follow-up. Changes over time were analyzed with mixed linear longitudinal models. Results. A sample of 510 patients (median 74 years, 58% male) and their caregivers (median 55 years, 75.5% female) were randomized to Arm 1 (n = 155), Arm 2 (n = 177) and Arm 3 (n = 178). Chest discomfort improved in Arms 1 and 2 versus Arm 3 at T4 (mean difference(Δ): -8.13, P = .014). Dyspnea also improved in Arms 1 and 2 than Arm 3 both at T3 and T4 (Δ: -7, P = .027 and Δ: -6.78, P = .038, respectively). HFSPS total score improved in Arms 1 and 2 versus Arm 3 at T3 (Δ: -4.55, P = .048). Over the year of observation, the mixed linear longitudinal models showed a significant improvement in Chest discomfort and total HFSPS score in Arm 2 versus Arm 3 (β = -2.61, P = .002 and, β = -1.35, P = .02). Conclusions. The results of this secondary analysis indicate that MI may be effective in decreasing the burden of physical symptoms in HF patients, especially if also caregivers are involved in the intervention. Since symptom burden is among the first reasons for seeking emergency care and hospitalization in HF, MI might be a viable option to improve symptom burden via self-care.

Does motivational interviewing reduce health services use and mortality in heart failure patients? A secondary analysis of the MOTIVATE-HF trial

Abstract Funding Acknowledgements Type of funding sources: Public Institution(s). Main funding source(s): Center of Excellence for Nursing Scholarship, Rome, Italy Background. Health services use and mortality are high among patients with heart failure (HF). The MOTIVATE-HF was a randomized controlled trial in which we demonstrated that Motivational Interviewing (MI) can effectively improve HF patient self-care (primary outcome). However, it is still unclear if MI can reduce health services use and mortality. Purpose. To test the efficacy of MI in reducing health services use (emergency services and hospitalizations), and all-cause mortality in HF patients. Methods. The MOTIVATE-HF was a multicenter parallel trial (1:1:1) with randomization of patient and informal caregiver dyads across three arms: Arm 1, MI administered to patients; Arm 2, MI administered to patients and caregivers; Arm 3, standard of care. Participants were enrolled from three Italian HF specialty centers. Patients were included only if they had HF in NYHA functional class II-IV and excluded if they had a recent coronary event, lived in a residential setting, or had severe cognitive impairment. Informal caregivers were nominated by the patients as the person mainly responsible for their care. The intervention consisted of one face-to-face MI session followed by 3 telephone contacts within 2 months from enrollment. Follow-up and reassessment occurred after 3-, 6-, 9- and 12-months post-randomization. A longitudinal generalized mixed model and a Cox proportional-hazard model were fitted to compare rates of health care services use and mortality among the three study arms during follow-ups. Results. The sample of 510 HF patients (median age 74 years; IQR 65-82; 58% male) was distributed as follows: Arm 1, n = 155; Arm 2, n = 177; and Arm 3, n = 178. Within the 12 months" period, 25 patients (16.1%) in Arm 1, 30 patients (17%) in Arm 2, and 20 patients (11.2%) in Arm 3 used health services at least once (p = 0.25) without significant differences at any follow up. Regarding all-cause mortality, at 3 months, 3 patients (1.9%) in Arm 1, 1 patient (0.6%) in Arm 2, and 9 patients (5.1%) in Arm 3 had died (p = 0.02). At 6 months, 5 patients (3.2%) in Arm 1, 1 patient (1.7%) in Arm 2 and 12 patients (6.7%) in Arm 3 had died (p = 0.05). No significant group differences were observed at 9 or 12 months. Mortality was lower in Arm 2 compared to Arm 3 in the first 3 months (HR = 0.112, 95% CI: 0.014–0.882, p = 0.038), whereas no difference was detected in the following months (p = 0.699). Mortality was also lower in Arm 1 compared to Arm 3 in the first 3 months, but this reduction did not reach statistical significance (HR = 0.383, 95% CI:0.104–1.414, p = 0.155). Conclusions. This analysis indicates that MI was not effective in reducing health services use in our sample, but it was effective in reducing all-cause mortality, at least in the short-term period. MI could be an inexpensive intervention to reduce HF mortality but further studies are needed to see if more frequent MI interventions could produce greater sustained reduction in health services use and mortality.

Comparative analysis of self-care assessment scales in patients with chronic heart failure, advantages and disadvantages

Aim To compare Russian versions of the scales for assessment of self-care ability in patients with chronic heart failure (CHF), European Heart Failure Self-Care Behavior Scale (EHFScBS_9) and The Self-Сare of Heart Failure Index (SCHFI, version 6.2).Materials and methods Assessment of the self-care ability was performed with Russian versions of EHFScBS_9 and SCHFI (version 6.2) scales in 130 patients with NYHA functional class II-IV CHF primarily of ischemic origin (78.5 %). Mean age of patients was 63.2±9.6 years; most of the patients were men (n=92; 70.8 %). Patients were managed in accordance with effective guidelines ESC / HFA 2016 and Russian guidelines 2018.Results Along with an increase in SСHFI scores, a decrease in EHFScBS_9 scores was observed (r= -0.31, p&lt;0.001). The patients participating in the study showed a low self-care ability at baseline according to results of both scales.Conclusion The presence of certain differences between the study scales does not exclude a possibility of using them alone or together for more detailed assessment of the self-care ability.

Clinical and laboratory associations of liver fibrosis indexes in patients with decompensated Chronic Heart Failure II-IV Functional Classes

Aim To study clinical and laboratory associations of hepatic fibrosis indexes in patients with decompensated NYHA functional class II-IV chronic heart failure (CHF).Material and methods The study included 128 patients admitted to the cardiological or therapeutic department of the University Clinical Hospital #4 at the I. M. Sechenov First Moscow State Medical University (Sechenov University) with symptoms of CHF associated with ischemic heart disease (IHD) and/or arterial hypertension (AH). All patients had signs of liver disease (liver enlargement on physical examination ± diffuse changes in hepatic tissue according to ultrasound data). Mean age was 70.59±10.71 years. Along with general clinical examination, severity of hepatic fibrosis was evaluated by calculated indexes, FIB-4, APRI, MELD-XI, and BARD. All calculations were based on laboratory data obtained within the first two days of hospitalization for decompensated CHF, at the onset of active therapy with intravenous diuretics. Statistical analyses were performed with the R programming language (3.6.1).Results In patients with NYHA FC II-IV CHF, the FIB-4 index significantly increased with the increase in NYHA FC (р&lt;0.05). Also, the high liver density by most fibrosis indexes correlated with the probability of LV EF decrease to &lt;40 % (FIB-4: RR, 1.32 at 95 % CI from 0.53 to 3.28, р=0.079; MELD-XI: RR, 1.62 at 95 % CI from 1.19 to 2.20, р=0.004; BARD: median LV EF, 42.5 % vs. 56 %, р=0.019), and a tendency to heart rhythm disorders was observed (FIB-4: RR, 1.92 at 95 % CI from 0.75 to 4.90, р=0.218; BARD: RR, 1.09 at 95 % CI from 0.97 to 1.22, р=0.174; MELD-XI: RR, 1.34 at 95 % CI from 0.94 to 1.90, р=0.101). Increases in liver fibrosis indexes correlated with other multiorgan disorders in CHF patients evident as a decrease in platelet count (FIB-4: р&lt;0.01; APRI: р=0.045) and a tendency to a decrease in hemoglobin (FIB-4: 127 g/l vs. 137 g/l, p=0.249; APRI: 127 g/l vs. 136 g/l, p=0.749). Patients with a high liver density more frequently had cardiorenal syndrome diagnosed by reduced glomerular filtration rate (GFR) estimated by CKD-EPI to less than 60 ml/min / 1.73 m2 (FIB-4: р&lt;0.03; MELD-XI: p=0.0001; BARD: р=0.005). In comparing liver fibrosis indexes in subgroups of CHF patients with preserved and reduced left ventricular ejection fraction (LV EF), significant differences were found only for MELD-XI (12.08 vs. 9.32, р=0.001).Conclusions For all studied indexes, correlations were observed with LV EF, decreases in hemoglobin, and incidence of heart rhythm disorders. For the BARD, FIB-4, and MELD-XI indexes, high results of calculations correlated with the presence of other predictors for unfavorable prognosis and disease severity (LV EF, NYHA FC, presence of type 2 diabetes mellitus, chronic kidney disease, and lower GFR). Liver fibrosis indexes are a new and promising but understudied instrument for evaluation of prognosis in CHF patients, which requires further study to determine most appropriate prognostic formulas.

Does the lack of left ventricular reverse remodeling always mean non - response to cardiac resynchronization therapy?

To evaluate clinical, morphological, functional features and mortality level in patients with different value of left ventricular reverse remodeling after cardiac resynchronization therapy (CRT). The study enrolled 112 patients (mean age 54.6±9.9 years, 83.5% men) with left ventricular ejection fraction (LVEF) І35%, NYHA functional class II-IV. We enrolled patients with QRS width >120 ms or QRS.

Full - transcriptome analysis of miRNA expression in mononuclear cells in patients with acute decompensation of chronic heart failure of various etiologies

Analysis of miRNA expression levels in mononuclear blood cells (MBC) of patients with acute decompensation f chronic heart failure (CHF) of various etiologies and evaluation of the possibility of their use as a biological marker. 7 male patients with acute decompensation of CHF with a reduced ejection fraction (EF), NYHA functional class II-IV (FC) according to NYHA [mean (M) EF 29.2%, standard deviation (SD) 13.27%] in age 38 to 65 years old [median (Me) 58 years]. In 3 patients, heart failure developed as a result of dilated cardiomyopathy (DCMP), in 4 patients - against the background of post - infarction cardiosclerosis of the ischemic nature [group of patients with coronary heart disease (CHD)]. The control group - 5 age - matched (from 41 to 57 years old, Me 49 years old) healthy male volunteers. A complete transcript analysis of miRNA expression in MNCs was performed for all patients and healthy volunteers. Differentially expressed miRNAs were determined in patients with CHF (regardless of etiology) compared with healthy individuals: miR-182, miR-144, miR-183, miR-486-5p, miR-143 (log2FC >1, FDR p - value.

Intravascular cells and circulating microparticles induce procoagulant activity via phosphatidylserine exposure in heart failure.

Relatively little information is known about the definitive role of phosphatidylserine (PS) in the hypercoagulability of heart failure (HF). Our objectives were to assess the levels of PS exposure on microparticles (MPs) and blood cells (BCs) in each group of HF patients and to evaluate their procoagulant activity (PCA). HF patients in each NYHA functional class II-IV (II n = 30, III n = 30, IV n = 30) and healthy controls (n = 25) were enrolled in the present study. PS exposure on MPs, BCs was analyzed with flow cytometry. MPs were classified based on their cellular origin: platelets (CD41a+), neutrophils (CD66b+), endothelial cells (CD31+CD41a-), erythrocytes (CD235a+), monocytes (CD14+), T lymphocytes (CD3+), and B lymphocytes (CD19+). PCA was evaluated by clotting time, extrinsic/intrinsic FXa and prothrombinase production assays, as well as fibrin formation assays. Inhibition assays of PCA of PS+ BCs and MPs were performed by lactadherin. There was no significant difference in MP cellular origin between healthy and HF subjects. However, the total number of PS+ MPs was significantly increased in HF patients compared with healthy controls. In addition, circulating PS+ BCs cooperated with PS+ MPs to markedly shorten coagulation time and dramatically increase FXa/thrombin generation and fibrin formation in each HF group. Moreover, blockade of exposed PS on BCs and MPs with lactadherin inhibited PCA by approximately 80%. Our results lead us to believe that exposing PS on the injured BCs and MPs played a pivotal role in the hypercoagulability state in HF patients.

Double-Blind, Randomized, Placebo-Controlled Trial Evaluating the Efficacy and Safety of Eplerenone in Japanese Patients With Chronic Heart Failure (J-EMPHASIS-HF).

The mineralocorticoid receptor antagonist eplerenone improved clinical outcomes among patients with heart failure with reduced ejection faction (HFrEF) in the EMPHASIS-HF (Eplerenone in Mild Patients Hospitalization And SurvIval Study in Heart Failure) study. However, similar efficacy and safety have not been established in Japanese patients. We evaluated the efficacy and safety of eplerenone in patients with HFrEF in a multicenter, randomized, double-blind placebo-controlled outcome study (ClinicalTrials.gov Identifier: NCT01115855). The aim of the study was to evaluate efficacy predefined as consistency of the primary endpoint with that of EMPHASIS-HF at a point estimate of <1 for the hazard ratio.Methods and Results:HFrEF patients with NYHA functional class II-IV and an EF ≤35% received eplerenone (n=111) or placebo (n=110) on top of standard therapy for at least 12 months. The primary endpoint was a composite of death from cardiovascular causes or hospitalization for HF. The primary endpoint occurred in 29.7% of patients in the eplerenone group vs. 32.7% in the placebo group [hazard ratio=0.85 (95% CI: 0.53-1.36)]. Hospitalization for any cause and changes in plasma BNP and LVEF were favorable with eplerenone. A total of 17 patients (15.3%) in the eplerenone group and 10 patients (9.1%) in the placebo group died. Adverse events, including hyperkalemia, were similar between the groups. Eplerenone was well-tolerated in Japanese patients with HFrEF and showed results consistent with those reported in the EMPHASIS-HF study.

Prevalence and prognostic value of hyponatremia on admission in hospitalized patients with heart failure

To investigate the prevalence and prognostic value of hyponatremia on admission in hospitalized patients for heart failure (HF) from the first HF management center in China. Consecutive adult (age of 18 years or older) symptomatic HF patients (NYHA functional class II-IV) admitted between March 2009 and March 2012 in our center were included in the present analysis. Hyponatremia was defined as a serum sodium level < 135 mmol/L. Association between hyponatremia on admission and in-hospital mortality as well as all-cause death and heart failure death during 1-year follow-up after discharge was analyzed. A total of 1 048 hospitalized patients for HF with complete baseline data were enrolled and the prevalence of hyponatremia on admission was 9.2% (96/1 048). Blood pressure was significantly lower while NYHA functional class and N-terminal pro-B type natriuretic peptide levels were significantly higher in hyponatremic patients than non-hyponatremic patients (all P < 0.05). Kaplan-Meier survival analysis showed that patients with hyponatremia on admission had significant higher in-hospital mortality (P < 0.01), all-cause death rate (P < 0.01) and HF death rate (P < 0.01) during 1-year follow-up post discharge compared with non-hyponatremic patients with. Multiple Cox proportional hazard analysis showed that hyponatremia on admission remained as independent predictor for all-cause death (hazard risk (HR) = 2.105, 95% confidence interval (CI) 1.460-3.036, P < 0.01) and HF death (HR = 2.458, 95% CI: 1.704-3.545, P < 0.01) after adjustment for other covariates. Hyponatremia is relatively common in patients hospitalized with HF in China and hyponatremia on admission is associated with higher in-hospital mortality and all-cause death and HF death one year after discharge.

Left ventricular mass and progenitor cells in chronic heart failure patients.

The aim of the study was to evaluate the association between circulating (CPCs) and endothelial (EPCs) progenitor cells and left ventricular (LV) remodeling in chronic heart failure (HF). 85 HF patients, ranging 29-89 years, 83.5% males, 45.9% ischemic, NYHA functional class II-IV, with a LV ejection fraction ≤40% were studied. LV ejection fraction, LV end-diastolic and end-systolic (LVESV) volumes, LV mass and tricuspid annular plane systolic excursion (TAPSE) were evaluated, and, when indicated, indexed for body surface area (BSA). CPCs and EPCs number was assessed using flow cytometry. CPCs were defined as CD34+, CD133+ and CD34+/CD133+. EPCs, identified through their expression of KDR, were defined as CD34+/KDR+, CD133+/KDR+ and CD34+/CD133+/KDR+. All EPCs were negatively related to LVESV/BSA (r = -0.24, p = 0.02 for all EPC's populations), and to LVmass/BSA (CD34+KDR+; r = -0.30, p = 0.005; CD133+KDR+; r = -0.31, p = 0.004; CD34+CD133+KDR+; r = -0.29, p = 0.007). No differences in EPCs levels in relation to cardiovascular risk factors, medications, etiology, age or gender were observed. CPCs number was higher in women, and lower in ischemic patients. In logistic regression analyses, the low EPCs' number was associated with an increased likelihood of abnormal LVmass/BSA. CPCs proved to be higher and EPCs lower in patients with severely abnormal LVmass/BSA (gr/m(2), ≥122 in women and ≥149 in men). Our results suggest a correlation between LV remodeling and progenitor cells. This is noteworthy considering that it has been suggested that bone marrow-derived EPCs participate in cardiac regeneration and function recovery in the setting of progressive HF.

Direct renin inhibition in addition to or as an alternative to angiotensin converting enzyme inhibition in patients with chronic systolic heart failure: rationale and design of the Aliskiren Trial to Minimize OutcomeS in Patients with HEart failuRE (ATMOSPHERE) study

The renin-angiotensin-aldosterone system (RAAS) represents a key therapeutic target in heart failure (HF) management. However, conventional agents that block this system induce a reflex increase in plasma renin activity (PRA), which may lead to RAAS 'escape'. Direct renin inhibitors (DRIs) have been developed that decrease PRA and thus may provide a greater RAAS blockade. Aliskiren is the first orally active DRI. Plasma levels of B-type natriuretic peptide (BNP) have been observed to be reduced with aliskiren compared with placebo. The aim of the Aliskiren Trial of Minimizing OutcomeS for Patients with HEart failuRE (ATMOSPHERE) study is to evaluate the effect of both aliskiren and enalapril monotherapy and aliskiren/enalapril combination therapy on cardiovascular death and HF hospitalization in patients with chronic systolic HF, NYHA functional class II-IV symptoms, and elevated plasma levels of BNP. Methods Patients tolerant to at least 10 mg or equivalent of enalapril will undergo an open-label run-in period where they receive enalapril then aliskiren. Approximately 7000 patients tolerating this run-in period will then be randomized 1:1:1 to aliskiren monotherapy, enalapril monotherapy, or the combination. The primary endpoints of ATMOSPHERE are (i) whether the aliskiren/enalapril combination is superior to enalapril monotherapy in delaying time to first occurrence of cardiovascular death or HF hospitalization and (ii) whether aliskiren monotherapy is superior or at least non-inferior to enalapril monotherapy on this endpoint. Perspective The ATMOSPHERE study will definitively determine the role of a DRI strategy additional to or as an alternative to conventional RAAS blockade in patients with chronic systolic HF.

Adiponectin and Myocardial Performance in Chronic Systolic Heart Failure: Potential Role in Compensation for Endothelial Dysfunction

Background: Plasma adiponectin levels are elevated in patients with chronic systolic heart failure (HF) and associated with adverse outcomes. In contrast, low adiponectin levels are related to endothelial dysfunction in non-HF setting. Herein, we examine the relationship between adiponectin and endothelial dysfunction in systolic HF. Methods: In 139 patients with HF (left ventricular [LV] ejection fraction ≤35%, NYHA functional class II-IV), we measured plasma adiponectin and asymmetric dimetharginine (ADMA, surrogate of endothelial dysfunction) levels and performed comprehensive echocardiography with assessment of cardiac structure and performance.

Prevalence, clinical characteristics and outcome in patients with chronic heart failure and diabetes

Background Chronic heart failure (CHF) and diabetes mellitus portend high morbidity and mortality because of an interrelated pathophysiologic process. This large cohort study aimed to analyze the prevalence, clinical characteristics and long-term outcome of patients with CHF and diabetes. Methods A total of 1119 patients with NYHA functional class II-IV and left ventricular ejection fraction (LVEF) &lt;45% between January 1995 and May 2009 were recruited. Clinical variables, biochemical and echocardiographic measurements were retrospectively reviewed, and composite major cardiac events (MCE) including death, heart transplantation, and refractory heart failure requiring multiple hospitalizations were recorded. Results The prevalence of CHF with diabetes was progressively increased with time (16.9% in 1995-1999; 20.4% in 2000-2004, and 29.1% in 2005-2009) and age (18.5% in &lt;60 years, 26.6% in 60-80 years, and 26.6% in &gt;80 years). Compared with CHF patients without diabetes, those with diabetes had worse cardiac function, more abnormal biochemical changes, and higher mortality. Treatment with glucose-lowering agents significantly improved LVEF and decreased MCE. An elevated serum HbA1c level was associated with large left ventricular end-systolic diameter (P &lt;0.05), decreased LVEF (P &lt;0.01) and reduced survival (P &lt;0.05). Multivariable Logistic regression analysis revealed that after adjustment for confounding factors, NYHA functional class (OR 2.65, 95% CI 1.14-6.16, P=0.024) and HbA1c level ≥7% (OR 2.78, 95% CI 1.00-7.68, P=0.049) were independent risk factors for adverse outcomes in CHF patients with diabetes. Conclusions Prevalence of CHF with diabetes was increasing during past decades, and patients with CHF and diabetes had worse clinical profiles and prognosis. Aggressive anti-CHF and diabetes therapies are needed to improve overall outcomes for these patients.

Stronger Prognostic Value of Plasma Adiponectin in Patients with Chronic Systolic Heart Failure and Lower Body Mass Indices: Implications on Disease Progression

Introduction: Adiponectin (ADPN) is secreted by adipocytes and has anti-atherogenic, anti-inflammatory and insulin-sensitizing properties. Recent data suggested high plasma ADPN levels are associated with poorer outcomes. We hypothesize that body mass index (BMI) may impact the prognostic value of ADPN in patients with chronic systolic heart failure. Methods: We evaluated 139 patients enrolled in the ADEPT study with chronic systolic heart failure (LVEF≤35%, NYHA functional class II-IV). Plasma ADPN levels were determined by sandwich enzyme-linked immunosorbent assay (Quantikine ELISA, R&D Systems, Minneapolis MN).

Exercise capacity can be estimated from systolic and diastolic echocardiographic indices

Background: Exercise capacity as measured by maximal rate of total oxygen consumption (VO2max) has been shown to be a powerful predictor of mortality in patients with congestive heart failure and is the best single measure of prognosis in this population. VO2max lacks consistent correlation with other prognostic factors such as left ventricular systolic function. This could be due to failure to account for diastolic function due to the parabolic nature of diastolic values. Both, diastolic and systolic functions are important in determining the overall function of the heart. Hypothesis: We hypothesize that VO2max can be predicted from the composite of systolic and linear diastolic parameters. Methods: We enrolled patients with congestive heart failure (NYHA functional class II-IV) without prior history of respiratory disease in our study. VO2max was measured during a modified Naughton exercise protocol. The resting left ventricular systolic function was assessed by measuring left ventricular ejection fraction (LVEF) by echocardiography. Diastolic function was assessed by mitral valve Doppler inflow and tissue Doppler imaging; and was reported as a diastolic class (DC): restrictive, pseudo-normalization, abnormal relaxation, and normal. Diastolic classes were given a numeric value of 1 to 4 consequently. Results: Twenty-four patients were included (4 females and 20 males). The mean LVEF was 31±14 % and the mean VO2max was 16±5 ml/kg/min. Five patients had a DC of 3, 9 patients had a diastolic class of 2, and 10 patients had a DC of 1. The relationship between left ventricular systolic and diastolic function indices with VO2max was analyzed by linear regression through the origin. LVEF and DC combined were strong predictors of VO2max (r=0.92). The regression equation reflecting the relationship was: VO2max=0.496 × LVEF+1.54 × DC. Conclusion: We found a good correlation between VO2max and the composite of systolic and diastolic indices determined by echocardiography. This stresses the importance of both systolic and diastolic function in congestive heart failure etiology, prognosis, and the ability to estimate VO2max and consequently the exercise capacity based on echocardiography data.

The acute haemodynamic effects of intravenous enalaprilic acid (MK422) in patients with left ventricular dysfunction.

Intravenous enalaprilic acid (2.5 mg) was given to 11 patients with stable cardiac failure (NYHA functional class II-IV). Reductions in mean right atrial, pulmonary artery and pulmonary capillary wedge pressure of 25%, 18% and 30% respectively (P less than 0.01), were observed. Cardiac output rose by 13% (NS) and mean blood pressure fell by 20% (P less than 0.01) with a decrease in systemic vascular resistance of 24% (P less than 0.01). Heart rate was unaltered. The haemodynamic effects correlated with control plasma renin activity (r = 0.78, P less than 0.01). Marked hypotension occurred in several subjects but no other side-effects were noted. The rapid onset of action and mixed venous and arteriolar dilating activity of intravenous enalaprilic acid may be an advantage in some clinical situations where parenteral vasodilating therapy is required.