Presence Of Chronic Heart Failure Research Articles

Abstract 18012: Insights into the Cardiorenal Syndrome Type II in the Rat

Cardiorenal Syndrome Type II (CRSII) is kidney function deterioration in the presence of Chronic Heart Failure (CHF). The mechanisms leading to kidney damage in CHF are however still obscure. We studied the development of kidney injury in a model of right CHF monocrotaline (MCT) treated rats. Methods: 10 Sprague-Dawley rats were treated with MCT for 4 weeks until they developed HF. 11 were taken as control (C). Heart failure was confirmed on transverse heart histologic sections looking at RV hypetrophy /dilatation and BNP plasma levels. Cytokine profile was assessed by Multiplex array on sera. pNGAL, pCreatinine (ELISA), kidney tissue NGAL (RT-PCR) were performed. Kidney cell apoptosis was assessed by TUNEL. Results: MCT rats showed higher BNP values (MCT 4.7±1.2 vs C 1.5±0.5pg/mL p<0.004 ), marked RV Hypetrophy and dilatation (RVMass/RVVolume MCT 1.46±0.31vs C 2.4±0.8 p<0.01). TNFα (MCT 1325.37±559.95vsC84.46±64.50 pg/ml ), IL1(MCT183.71±51.61vsC78.31±26.07), IL4 (MCT 731.67±154.83 vs C 316.62±12.55pg/ml), IL6 (MCT 5314.983±1632.98 vs C1754.01±188.85), IL10 (MCT2613.10±934.04vs C847.70±152.19 pg/ml) were all increased (p<0.05) as well as Creatinine (MCT 0.95±0.4 vs C 0.57±0.4 ug/mL, p<0.05). Both plasma (MCT 0.56±0.28 vs C 0.25±0.16 ug/mL,p<0.02) and kidney tissue NGAL (MCT 70.7±8.7vs C 32.1±9.9 AU, p<0.001) were significantly increased and a higher number of kidney apoptotic cells was found (MCT 184.01±47.6 vs C 16.3±11.6 cells/mm2, p< 0.0001). In C rats apoptosis was found only on tubular or vascular cells, while in MCT also a lot of interstitial cells was found. In MCT rats apoptosis was found in medullar part of kidney with focal aspect. Conclusion: CHF in the rat is accompanied by deterioration of kidney function (CRSII). A rise of creatinine and NGAL, an early biomarker of kidney damage, was detected. Kidney cells apoptosis triggered by circulating pro-inflammatory cytokines represent the final insult to the kidney due to the CHF-induced perturbation of neuro-endocrine and inflammatory milieu.

Insights into the pathophisiology of cardiorenal syndrome type II in the rat

Background: Cardiorenal Syndrome Type II (CRSII) is kidney function deterioration in the presence of Chronic Heart Failure (CHF). The mechanisms leading to kidney damage in CHF are however still obscure.We studied the development of kidney injury in a model of right CHF (monocrotaline (MC) treated rats). Methods: 10 animals were treated with MC for 4 weeks until they developed HF. 11 were taken as control. The occurrence of HF wasdemonstrated by signs of congestion, hypertrophy and dilatation of the right ventricle, and by the determination of BNP. We measured pNGAL, pCreatinine (ELISA), kidney NGAL (RT-PCR), and pTNFα, IL1, IL4, IL6, IL10 (Multiplex protein microarray). Kidney cell apoptosis was assessed by TUNEL. Results: MC treated rats showed higher BNP values (MC 4.7±1.2, C 1.5±0.5 pg/mL p<0.004), marked RV Hypetrophy and dilatation (RVMass/RVVolume MC 1.46±0.31 C 2.4±0.8 p<0.01), pleural and peritoneal effusions. TNFα (MC 1325.37±559.95 vs C 84.46±64.50 pg/ml), IL1 (MC183.71±51.61 vs C 78.31±26.07 pg/ml), IL4 (MC 731.67±154.83 vs C 316.62±12.55 pg/ml), IL6 (MC 5314.983±1632.98 vs C 1754.01±188.85 pg/ml), IL10 (MC 2613.10±934.04 vs C 847.70±152.19 pg/ml) were all increased (p<0.05) as well as Creatinine (MC 0.95±0.4 vs C 0.57±0.4 pg/ml p<0.05). Both plasma (MC 0.56±0.28 vs C 0.25±0.16 ug/mL,p<0.02) and renal NGAL (MC 70.7±8.7 vs C 32.1±9.9 AU, p<0.001) were significantly increased and a higher number of kidney apoptotic cells was found (MC 69.3±1.6 vs C32.2±2.9 cells/mm2, p<0.04). Conclusion: CHF in the rat is accompanied by deterioration of kidney function (CRSII). A rise of creatinine and NGAL, an early biomarker of kidney damage, was detected. Kidney cells apoptosis triggered by circulating pro-inflammatory cytokines represent the final insult to the kidney due to the CHF-induced perturbation of neuro-endocrine and inflammatory milieu

Moderate alcohol consumption predicts long-term mortality in elderly subjects with chronic heart failure.

Moderate alcohol consumption is related to a reduction of mortality. However, this phenomenon is not well established in the elderly, especially in the presence of chronic heart failure (CHF). The aim of the study was to verify the effect of moderate alcohol consumption on 12-year mortality in elderly community-dwelling with and without CHF. community-dwelling from 5 regions of Italy. A cohort of 1332 subjects aged 65 and older. Mortality after 12-year follow-up in elderly subjects (≥65 years old) with and without CHF was studied. Moderate alcohol consumption was considered ≤250 ml/day (drinkers). In the absence of CHF (n=947), mortality was 42.2% in drinkers vs. 53.7% in non-drinker elderly subjects (p=0.021). In contrast, in the presence of CHF (n=117), mortality was 86.5% in drinkers vs. 69.7% in non-drinker elderly subjects (p=0.004). Accordingly, Cox regression analysis shows that a moderate alcohol consumption is protective of mortality in the absence (HR=0.79; CI 95% 0.66-0.95; p<0.01) but it is predictive of mortality in the presence of CHF (HR=1.29; CI 95% 1.05-1.97; p<0.05). Our data demonstrates that moderate alcohol consumption is associated with an increased long-term mortality risk in the elderly in the presence of CHF.

Circulation: Clinical Summaries

<i>Circulation:</i> Clinical Summaries

Cardiomyogenesis in the Aging and Failing Human Heart

Two opposite views of cardiac growth are currently held; one views the heart as a static organ characterized by a large number of cardiomyocytes that are present at birth and live as long as the organism, and the other views the heart a highly plastic organ in which the myocyte compartment is restored several times during the course of life. The average age of cardiomyocytes, vascular endothelial cells (ECs), and fibroblasts and their turnover rates were measured by retrospective (14)C birth dating of cells in 19 normal hearts 2 to 78 years of age and in 17 explanted failing hearts 22 to 70 years of age. We report that the human heart is characterized by a significant turnover of ventricular myocytes, ECs, and fibroblasts, physiologically and pathologically. Myocyte, EC, and fibroblast renewal is very high shortly after birth, decreases during postnatal maturation, remains relatively constant in the adult organ, and increases dramatically with age. From 20 to 78 years of age, the adult human heart entirely replaces its myocyte, EC, and fibroblast compartment ≈8, ≈6, and ≈8 times, respectively. Myocyte, EC, and fibroblast regeneration is further enhanced with chronic heart failure. The human heart is a highly dynamic organ that retains a remarkable degree of plasticity throughout life and in the presence of chronic heart failure. However, the ability to regenerate cardiomyocytes, vascular ECs, and fibroblasts cannot prevent the manifestations of myocardial aging or oppose the negative effects of ischemic and idiopathic dilated cardiomyopathy.

Detection of left main coronary artery stenosis: utilization of transesophageal echocardiography in acute heart failure

A previously healthy 80-year-old male with a history of type II diabetes mellitus was referred to our emergency department because of severe dyspnoea. Physical examination revealed a diaphoretic man with a blood pressure of 105/65 mmHg, a low oxygen saturation of 85% and diffuse inspiratory crackles and rales on auscultation. The electrocardiogram showed a sinus tachycardia of 110 beats/min with a left bundle branch block. A chest X-ray of the lungs revealed pulmonary oedema. Arterial blood gas analysis indicated respiratory acidosis requiring intubation and ventilation. Immediate transoesophageal echocardiography (TEE) was performed to search for signs of suspected acute ischaemia. The echocardiogram pointed out a dilated left ventricle with severe hypokinesia of all wall segments. There was a moderate secondary mitral regurgitation due to the left ventricular dysfunction and annular dilatation. The aortic valve appeared normal without any signs of stenosis. The echocardiogram suggested the presence of chronic heart failure until colour Doppler analysis of the aortic valve revealed a mosaic flow pattern in the left main coronary artery suggesting a severe stenosis (Fig. 1a). Urgent cardiac catheterisation confirmed a pinpoint stenosis of the left main coronary artery (Fig. 1b). Subsequently, coronary artery bypass grafting was performed with maximum CK-MB of 55 μg/L, and the patient recovered uneventfully. Fig. 1 a Colour Doppler analysis reveals mosaic flow in the left main coronary artery suggestive of a severe stenosis with the aortic valve showing no signs of obstruction; b In the LAO view the pinpoint left main coronary artery stenosis is confirmed Transthoracic echocardiography can adequately assess coronary flow in approximately half of patients [1]. Normally, the colour flow pattern in the coronary artery is consistent with laminar flow. Diastolic mosaic flow caused by focal flow acceleration indicates significant left main coronary artery stenosis in 85% of patients. Peak diastolic velocities greater than 1.5 m/s are considered abnormal [1]. TEE can visualise haemodynamically significant stenosis of the left main as well as primarily proximal segments of the left anterior descending, circumflex and right coronary artery in the majority of patients [2]. Our case stresses the diagnostic power of a carefully performed TEE in haemodynamically unstable patients of unknown cause.

Importance of ventricular longitudinal function in chronic heart failure

Despite its immediate relevance, cardiopulmonary exercise testing (CPET) is infrequently performed in the presence of chronic heart failure (CHF). Previous studies of patients suffering from CHF have found a closer correlation between exercise capacity and measurements of diastolic than systolic ventricularfunction. We examined the correlation between echocardiographic measurements and (i) results of CPET and (ii) cardiovascular prognosis. We performed resting two-dimensional echocardiograms and CPET in 140 patients with CHF (mean age = 61 ± 13 years, 111 men). The underlying heart disease was ischaemic in 48 patients (34%). They were followed for a mean of 38 months (range 28-52). The mean left ventricular (LV) ejection fraction (EF) was 30 ± 9% and peak VO₂ 17.2 ± 6.5 mL/kg/min. LVEF correlated weakly with peak VO₂ (r = 0.21), while systolic and early diastolic LV longitudinal function correlated best [early diastolic peak velocity at the mitral annulus (E'): r = 0.38; global longitudinal strain (GLS): r = -0.4; P <0.001 for both]. By multiple variable regression analysis, the best prediction of peak VO₂ was derived from a model based on age, mitral annulus end-diastolic peak velocity (A'), GLS, right ventricular (RV) systolic strain, and left atrial systolic strain (r² = 0.57; P <0.0001). The two best independent predictors of adverse cardiovascular events at 28 months were GLS (odds ratio 1.31, P <0.001; prognostic cut-off = -8%) and RV systolicstrain (odds ratio 1.05, P =0.01; prognostic cut-off = -22%). Resting RV and LV longitudinal functions were reliable predictors of adverse cardiovascular events and correlated moderately with, but not took to the place of, CPET measurements.

Role of permanent atrial fibrillation (AF) on long-term mortality in community-dwelling elderly people with and without chronic heart failure (CHF)

Permanent AF is characterized by an increased mortality in elderly subjects with CHF. Moreover, AF increased the risk of mortality also in elderly subjects without CHF. Thus, we examined long-term mortality in community-dwelling elderly people with and without CHF. A total of 1332 subjects aged 65 and older were selected from the electoral rolls of Campania, a region of southern Italy. The relationship between AF and mortality during a 12-year follow-up in 125 subjects with CHF and in 1.143 subjects without CHF were studied. Elderly subjects showed a higher mortality in those with respect to those without AF (72.1% vs. 51.8%; p<0.01). Similarly, elderly subjects without CHF showed a higher mortality in those with respect to those without AF (61.8% vs. 49.8%; p<0.05). In contrast, elderly subjects with CHF showed a similar mortality in those with respect to those without AF (74.7% vs. 82.4%; p=0.234). Multivariate analysis shows that AF was predictive of mortality in all elderly subjects (Hazard Risk=HR=1.39, 95% confidence interval (CI)=1.25–2.82; p<0.001). When the analysis was conducted considering the presence and the absence of CHF, AF was strongly predictive of mortality in elderly subjects without CHF (HR=1.95, 95%CI=1.25–4.51; p<0.001) but not in those with CHF (HR=1.12, 95%CI=0.97–3.69; p=0.321). We concluded that AF is able to predict long-term mortality in elderly subjects. Moreover, AF is strongly predictive of long-term mortality in the absence but not in the presence of CHF.

Depressive symptoms predict mortality in elderly subjects with chronic heart failure

Chronic heart failure (CHF) is characterized by a high mortality in the elderly. Moreover, depression status is also related to poor prognosis in advancing age. Thus, we sought to determine whether depressive status predicts long-term mortality in subject with or without CHF. Long-term mortality after 12-year follow-up in 125 elderly subjects with CHF and 1143 elderly subjects without CHF was studied. Depression was evaluated using the Geriatric Depression Scale (GDS), and all subjects were stratified in tertiles according to GDS score (0-10, 11-20 and 21-30). With increasing GDS score, long-term mortality at the end of follow-up increased from 43·4% to 72·0% in subjects without (P < 0·001) and from 52·6% to 83·9% in subjects with (P < 0·007) CHF. In multivariate analysis, GDS appeared to be predictive of long-term mortality in the absence (Hazard ratio = 1·01; confidence interval 95% 1·00-1·05; P = 0·04) and, even more, in the presence of CHF (Hazard ratio = 1·08; confidence interval 95% 1·01-1·15; P < 0·01). Depression symptoms predict long-term mortality in elderly subjects without and, even more, with CHF. Thus, depression can be considered a strong predictor of death in CHF elderly subjects.

Increased serum levels of S100B are related to the severity of cardiac dysfunction, renal insufficiency and major cardiac events in patients with chronic heart failure

Objective To investigate the correlations between S100B and the severity of cardiac dysfunction, renal insufficiency (RI) and prognosis in chronic heart failure (CHF). Method Serum levels of S100B, TNF-α, high sensitivity CRP and NT-proBNP were determined in CHF patients with (n = 96) and without RI (n = 146). Patients with RI only (n = 62) and control subjects (n = 64) served for comparison. Patients were followed up for one year. Results S100B levels were higher in CHF patients with a further elevation in those with RI (P < 0.01). Serum S100B levels correlated with left ventricular ejection fraction, left ventricular end-diastolic volume and NT-proBNP in CHF patients, and eGFR in patients with RI (all P < 0.05). Increased S100B levels were associated with major cardiac events (MCE), and were independently associated with the presence of CHF (all P < 0.05). Conclusion Increased serum S100B levels were associated with the severity of cardiac dysfunction, RI and an adverse prognosis in CHF patients. It represents an independent risk factor for CHF.

112 Importance of ventricular longitudinal function in chronic heart failure

Despite its immediate relevance, cardio-pulmonary exercise testing (CPET) is infrequently performed in presence of chronic heart failure (CHF). Previous studies of patients suffering from CHF have found a closer correlation between exercise capacity and measurements of diastolic than systolic ventricular function. We examined the correlation between echocardiographic measurements and a) results of CPET and b) cardiovascular prognosis. We performed resting two-dimensional echocardiograms and CPET in 140 patients with CHF (mean age = 61 ± 13 years, 111 men). The underlying heart disease was ischemic in 48 patients. They were followed for a mean of 38 months (range 28–52). The mean left ventricular (LV) ejection fraction (EF) was 30 ± 9%, and peak VO 2 17.2 ± 6.5 ml/kg/min. LVEF correlated weakly with peak VO 2 (r = 0.21), while systolic and early diastolic LV longitudinal function correlated best [early diastolic peak velocity at the mitral annulus (e’): r = 0.38; global longitudinal strain (GLS): r = −0.4; p < 0.001 for both]. By multiple variable regression analysis, the best prediction of peak VO 2 was derived from a model based on age, mitral annulus end-diastolic peak velocity (a’), GLS, right ventricular (RV) systolic strain and left atrial systolic strain (r 2 = 0.57; p < 0.0001). The 2 best independent predictors of adverse cardiovascular events at 28 months were GLS (odds ratio 1.31, p < 0.001; prognostic cut-off = −8%) and RV systolic strain (odds ratio 1.05, p = 0.01; prognostic cut-off −22%). Resting RV and LV longitudinal functions explained the presence of exercise intolerance and were more reliable predictors of adverse cardiovascular events than CPET measurements.

Waist Circumference but Not Body Mass Index Predicts Long‐Term Mortality in Elderly Subjects with Chronic Heart Failure

To examine whether waist circumference (WC) and body-mass index (BMI) can predict long-term mortality in elderly subjects with and without chronic heart failure (CHF). Longitudinal evaluation with a 12-year follow-up. Campania, a region of southern Italy. One thousand three hundred thirty-two subjects aged 65 and older selected from the electoral rolls of Campania. The relationship between WC or BMI and mortality during a 12-year follow-up in 125 subjects with and 1,143 subjects without CHF. Mortality increased as WC increased in elderly subjects without CHF (from 47.8% to 56.7%, P=.01), and the increase was even greater in patients with CHF (from 58.1% to 82.0%, P=.01). In contrast, mortality decreased as BMI increased in elderly subjects without CHF (from 53.8% to 46.1%, P0=.046) but not in those with CHF. According to Cox regression analysis, BMI protected against long-term mortality in the absence but not in the presence of CHF. In the absence of CHF, WC was associated with a 2% increased risk of long-term mortality for each 1-cm greater WC (Hazard Ratio (HR)=1.02, 95% confidence interval (CI)=1.01-1.03; P<.001), versus 5% increased in the presence of CHF (HR=1.06, 95% CI=1.02-1.10; P<.001). WC, but not BMI, is predictive of long-term mortality in elderly individuals with CHF and to a lesser extent in those without CHF.

Acute care costs of patients admitted for management of chronic obstructive pulmonary disease exacerbations: contribution of disease severity, infection and chronic heart failure

In 2003, chronic obstructive pulmonary disease (COPD) accounted for 46% of the burden of chronic respiratory disease in the Australian community. In the 65-74-year-old age group, COPD was the sixth leading cause of disability for men and the seventh for women. To measure the influence of disease severity, COPD phenotype and comorbidities on acute health service utilization and direct acute care costs in patients admitted with COPD. Prospective cohort study of 80 patients admitted to the Royal Melbourne Hospital in 2001-2002 for an exacerbation of COPD. Patients were followed for 12 months and data were collected on acute care utilization. Direct hospital costs were derived using Transition II, an activity-based costing system. Individual patient costs were then modelled to ascertain which patient factors influenced total direct hospital costs. Direct costs were calculated for 225 episodes of care, the median cost per admission was AU$3124 (interquartile range $1393 to $5045). The median direct cost of acute care management per patient per year was AU$7273 (interquartile range $3957 to $14 448). In a multivariate analysis using linear regression modelling, factors predictive of higher annual costs were increasing age (P= 0.041), use of domiciliary oxygen (P= 0.008) and the presence of chronic heart failure (P= 0.006). This model has identified a number of patient factors that predict higher acute care costs and awareness of these can be used for service planning to meet the needs of patients admitted with COPD.

Comorbidities in heart failure: a key issue

Comorbidities in heart failure: a key issue

Elevated angiogenin levels in chronic heart failure

Background. Abnormal indices of angiogenesis have been reported in chronic heart failure (CHF). We tested the hypothesis that circulating angiogenin (a potent inducer of neovascularization in vivo) is higher in CHF patients compared with controls and associated with indices of CHF severity: brain natriuretic peptide (BNP), Simpson's left ventricular ejection fraction (EF), and New York Heart Association (NYHA) class.Methods. Using a cross-sectional approach, we measured serum angiogenin and BNP levels in 109 consecutive patients with CHF (85 males; mean age 60 (standard deviation (SD) 10 yrs) and 112 asymptomatic controls with normal cardiac function and related levels to echocardiographic parameters.Results. Angiogenin was significantly higher in CHF patients compared to controls (P<0.001). On univariate analysis, angiogenin was positively associated with age, plasma glucose, insulin, and BNP (all P<0.001); and negatively correlated with diastolic blood pressure (P=0.04) and EF (P=0.002). Angiogenin levels increased in an ordinal fashion with NYHA class, exaggerated by the presence of diabetes mellitus (pseudo R2=0.15, P<0.001). In multivariate analysis, angiogenin levels were only associated with deteriorating NYHA classification (beta=0.14 (95% confidence interval (CI) 0.09–0.19), P<0.001). Angiogenin was also a modest discriminator for the presence of CHF (area under the curve 0.72; 95% CI 0.62–0.82), P<0.001).Conclusion. Angiogenin is related to worsening heart failure severity (NYHA classification), with the highest levels in NYHA class III. Further research is warranted to determine the validity of angiogenin in a diagnostic and prognostic capacity in CHF.

Development of Right Ventricular Dysfunction in Acute Myocardial Infarction and Chronic Heart Failure

Objective: to evaluate the structural and functional state of the right cardiac cavities in acute left ventricular myocardial infarction and in progressive chronic heart failure (CHF) in patients with coronary heart disease. Materials and methods. 20 patients with acute myocardial infarction and 48 with postinfarct cardiosclerosis with NYHA functional classes I to IV CHF were examined. The structural and functional state of the right heart was evaluated in progressive left ventricular systolic and diastolic dysfunction by echocardiography. Results. In the acute period of infarction, remodeling processes occur in the left ventricle, with normal postload values, volumetric indices and right ventricular contractility are in the normal range. There is right cardiac dilatation at the early stage of left ventricular systolic and diastolic dysfunction in postinfarct remodeling and evolving CHF, normal pulmonary arterial and right atrial pressures. With a significant reduction in left ventricular contractility and its pronounced filling impairment, increases in post- and preload for the right ventricle occur with a just considerable change in its structural and functional state. Conclusion. In impaired myocardial relaxation in the presence of CHF, remodeling of the right cardiac cavities takes place without the influence of a hemodynamic factor. There is a close relationship of remodeling of both ventricles from the very early CHF stages, which suggests that there are common pathogenetic mechanisms responsible for the development of myocardial dysfunction.

Life expectancy of elderly and very elderly patients with chronic heart failure

The survival of patients with chronic heart failure is typically reported as a comparison of different groups of patients using the hazard ratio from a Cox proportional hazards analysis. The absolute survival is generally neglected. Furthermore, attention is often focused on relatively young patients although chronic heart failure largely affects older patients. The present study was undertaken to determine the life expectancy (a measure of absolute survival) of older patients with chronic heart failure. Patients >75 years with chronic heart failure caused by impaired left ventricular systolic function who attended an outpatient clinic were included in the study. Follow-up commenced on August 1, 1993, and continued until September 30, 2005, when vital status was ascertained. Mean survival time was calculated as a measure of life expectancy. There were 210 patients included in the study. Male patients of mean age 80 years had a life expectancy of 3.9 years (95% CI 3.2-4.5), compared with that of 7 years for men in the general population of the same age. For female patients of mean age 80 years, the life expectancy was 4.5 years (95% CI 3.6-5.7), compared with 8.5 years for the general population of women of the same age. The presence of chronic heart failure in older patients results in an approximately 50% reduction in life expectancy.

Determinants of Thoracic Electrical Impedance in External Electrical Cardioversion of Atrial Fibrillation

The success of external cardioversion (ECV) of atrial fibrillation depends on generating sufficient transmyocardial current for defibrillation with minimal myocardial injury. Thoracic electrical impedance plays an important role in the relation between the delivered energy and transmyocardial current. This study assessed the determinants of thoracic electrical impedance in ECV of atrial fibrillation. ECV of atrial fibrillation was performed in 80 consecutive patients (mean age 73 +/- 9 years; men 69%; body mass index 26.0 +/- 3.6 kg/m(2)) within 12 months, using biphasic shocks (Multipulse Biowave) delivered through adhesive pads in an anteroposterior position. Thoracic electrical impedance was measured using the first shock. The mean thoracic electrical impedance was 57.7 +/- 12.3 Omega (energy 71 +/- 43 J, current intensity 33 +/- 12 A). Sinus rhythm was immediately restored in 75 patients (94%). Thoracic electrical impedance was greater (60.9 +/- 11.8 vs 51.7 +/- 11.0 Omega, p = 0.001) in patients requiring >1 shock (65%). At multivariate linear regression analysis (R = 0.761, p <0.001), female gender (+9.7 +/- 2.0 Omega, p <0.001), body mass index (+1.5 +/- 0.3 for a 1 kg/m(2) increase, p <0.001), hemoglobin concentration (+1.9 +/- 0.6 for a 1 g/dl increase, p = 0.004), and the presence of chronic heart failure (-5.3 +/- 2.0 Omega, p = 0.009) were independent predictors of thoracic electrical impedance. In conclusion, to increase ECV efficacy and minimize complications, the delivered energy should be adjusted in accordance with the clinical variables that independently affect thoracic electrical impedance and, hence, transmyocardial current.

Observational data suggesting there are electrocardiographic abnormalities that strongly suggest the presence of chronic heart failure

Almost nothing is written about the electrocardiographic abnormalities that may suggest the presence of chronic heart failure. Indeed, one often hears that the electrocardiogram does not indicate anything about the function of the ehart. This paper discusses several abnormalities that often predict the presence of chronic heart failure. The information presented is from observations and not from scientific studies. The author urges those who are interested to complete a scientific study based on the premise that such observations may be correct. After all, many scientific studies have been created because of observational data that suggested a certain phenomenon.

Drug treatment of stable angina pectoris in the elderly: defining the place of calcium channel antagonists.

Chronic stable angina pectoris (CSAP) resulting from coronary artery disease (CAD) is common in elderly patients, and significantly reduces their quality of life. Myocardial revascularisation procedures in this age group entail significant risks, largely related to comorbidities rather than advanced age itself. Coronary artery anatomy is more likely to be technically unsuitable for revascularisation and angina more resistant to drug treatment. Therefore, elderly patients often take combinations of antianginal drugs. Calcium channel antagonists (CCAs) are effective antianginal drugs first introduced for clinical use in the late 1970's. They reduce myocardial ischaemia by both causing vasodilatation of coronary resistance vessels and reducing cardiac workload (negative inotropic effect). However, adverse effects related to abrupt arterial vasodilatation limited the tolerability of these short acting 'first generation' drugs (nifedipine, verapamil and diltiazem). Furthermore, short acting nifedipine may occasionally increase both the frequency of angina pectoris and mortality in patients with CAD. Since then, long acting formulations of first generation agents and new chemical entities (second and third generation drugs) have been developed. These are well tolerated and effective at attenuating both myocardial ischaemia and the frequency and severity of angina pectoris in most patients with stable CAD. Current guidelines on the drug treatment of CSAP propose that beta-adrenoceptor antagonists (beta-blockers) should be used as first line medication primarily for their prognostic benefits, and that CCAs need only be introduced if beta-blockers are not tolerated, contraindicated or ineffective. Despite this, there is a wealth of evidence from clinical trials that demonstrate equal antianginal efficacy for CCAs and beta-blockers. The presence of chronic heart failure and prior myocardial infarction are clear indications for the use of beta-blockers in preference to CCAs for the treatment of CSAP. However, in patients with both CSAP and hypertension, second and third generation CCAs may offer prognostic benefits of similar magnitude to those provided by beta-blockers. Therefore, antianginal drug therapy must be tailored to the individual needs and comorbidities of each elderly patient.