Treatment Of Congestive Heart Failure Research Articles

Successful Treatment of Congestive Heart Failure Due to Severe Aortic Valve Stenosis With Low Dose Tolvaptan in Elderly Patients.

Medical therapy for severe aortic valve stenosis (AS) is necessary for inoperable patients due to comorbid conditions. Tolvaptan (TLV), unlike other diuretics, resulted in modest changes in filling pressures associated with an increase in urine output, suggesting that TLV improves congestive heart failure (CHF) due to severe AS without hemodynamic instability.We retrospectively investigated 14 consecutive patients ≥ 80 years of age admitted due to decompensated CHF with severe AS at Juntendo University Hospital from April 2014 to November 2015. Seven of the 14 patients were treated with TLV. We examined the safety and efficacy of TLV treatment for severe AS.Mean age was 90.0 ± 6.3 years and mean aortic valve area was 0.57 ± 0.22 cm2. Urine volume at day 1 of TLV treatment was increased and urine osmolality significantly decreased at day 1 of TLV treatment (all P < 0.05). New York Heart Association classification and brain natriuretic peptide levels significantly improved 1 week after treatment and at discharge (all P < 0.05) whereas brain natriuretic peptide levels did not improve in the patients without TLV. Severe adverse events did not occur during TLV treatment. During the first 3 days, blood pressure and heart rate were relatively stable. TLV treatment did not affect serum creatinine, blood urea nitrogen, or the estimated glomerular filtration rate.In elderly patients with severe AS, TLV treatment improved CHF without hemodynamic instability. Further prospective studies are needed to assess the safety and efficacy of TLV in decompensated heart failure due to severe AS.

VAGUS NERVE STIMULATION IN CARDIOLOGY

This article reviews key experimental and clinical studies that have taken place in the field of cardiology. Vagus nerve stimulation affects neuronal chains of extrinsic and intrinsic cardiac plexuses that enhance the parasimpatic influence. The positive therapeutic effect in the treatment of supraventricular and ventricular rhythm disorders, chronic cardiac failure and myocardial infarction has been achieved in different experimental and clinical trials. It has been shown that vagus nerve stimulation reduces atrial fibrillation relapse, lowers the risk of ventricular fibrillation and reduces the risk of ventricular tachycardias. After successful pre-clinical studies in congestive heart failure treatment with vagus nerve stimulation, this method started to be investigated in multicenter trials. Their early results are given in the article.

Stem cell therapy for chronic ischaemic heart disease and congestive heart failure.

A promising approach to the treatment of chronic ischaemic heart disease and congestive heart failure is the use of stem cells. The last decade has seen a plethora of randomised controlled trials developed worldwide, which have generated conflicting results. The critical evaluation of clinical evidence on the safety and efficacy of autologous adult bone marrow-derived stem/progenitor cells as a treatment for chronic ischaemic heart disease and congestive heart failure. We searched CENTRAL in the Cochrane Library, MEDLINE, Embase, CINAHL, LILACS, and four ongoing trial databases for relevant trials up to 14 December 2015. Eligible studies were randomised controlled trials comparing autologous adult stem/progenitor cells with no cells in people with chronic ischaemic heart disease and congestive heart failure. We included co-interventions, such as primary angioplasty, surgery, or administration of stem cell mobilising agents, when administered to treatment and control arms equally. Two review authors independently screened all references for eligibility, assessed trial quality, and extracted data. We undertook a quantitative evaluation of data using random-effects meta-analyses. We evaluated heterogeneity using the I2 statistic and explored substantial heterogeneity (I2 greater than 50%) through subgroup analyses. We assessed the quality of the evidence using the GRADE approach. We created a 'Summary of findings' table using GRADEprofiler (GRADEpro), excluding studies with a high or unclear risk of selection bias. We focused our summary of findings on long-term follow-up of mortality, morbidity outcomes, and left ventricular ejection fraction measured by magnetic resonance imaging. We included 38 randomised controlled trials involving 1907 participants (1114 cell therapy, 793 controls) in this review update. Twenty-three trials were at high or unclear risk of selection bias. Other sources of potential bias included lack of blinding of participants (12 trials) and full or partial commercial sponsorship (13 trials).Cell therapy reduced the incidence of long-term mortality (≥ 12 months) (risk ratio (RR) 0.42, 95% confidence interval (CI) 0.21 to 0.87; participants = 491; studies = 9; I2 = 0%; low-quality evidence). Periprocedural adverse events associated with the mapping or cell/placebo injection procedure were infrequent. Cell therapy was also associated with a long-term reduction in the incidence of non-fatal myocardial infarction (RR 0.38, 95% CI 0.15 to 0.97; participants = 345; studies = 5; I2 = 0%; low-quality evidence) and incidence of arrhythmias (RR 0.42, 95% CI 0.18 to 0.99; participants = 82; studies = 1; low-quality evidence). However, we found no evidence that cell therapy affects the risk of rehospitalisation for heart failure (RR 0.63, 95% CI 0.36 to 1.09; participants = 375; studies = 6; I2 = 0%; low-quality evidence) or composite incidence of mortality, non-fatal myocardial infarction, and/or rehospitalisation for heart failure (RR 0.64, 95% CI 0.38 to 1.08; participants = 141; studies = 3; I2 = 0%; low-quality evidence), or long-term left ventricular ejection fraction when measured by magnetic resonance imaging (mean difference -1.60, 95% CI -8.70 to 5.50; participants = 25; studies = 1; low-quality evidence). This systematic review and meta-analysis found low-quality evidence that treatment with bone marrow-derived stem/progenitor cells reduces mortality and improves left ventricular ejection fraction over short- and long-term follow-up and may reduce the incidence of non-fatal myocardial infarction and improve New York Heart Association (NYHA) Functional Classification in people with chronic ischaemic heart disease and congestive heart failure. These findings should be interpreted with caution, as event rates were generally low, leading to a lack of precision.

A new solvate of furosemide with dimethylacetamide.

The loop diuretic furosemide is used widely in the treatment of congestive heart failure and edema, and is practically insoluble in water. The physicochemical and pharmacokinetic properties of drugs can be modified by preparing the drug in an appropriate solid-state form. A new solvate of furosemide with dimethylacetamide (DMA) {systematic name: 4-chloro-2-[(furan-2-yl)methylamino]-5-sulfamoylbenzoic acid N,N-dimethylacetamide disolvate}, C12H11ClN2O5S·2C4H9NO, (I), is reported. The channeled structure formed on slow crystallization contains DMA solvent molecules in its channels. This structure adds to the evidence of varied conformations observed across all known structures, so supporting the idea that this flexible molecule has conformational lability. The current structure also differs from those of other previously known furosemide solvates in the number of solvent molecules per furosemide molecule, viz. 2:1 instead of 1:1. Desolvation of (I) gives the most stable form of furosemide, i.e. Form I.

Pharmacokinetic study of furosemide incorporated PLGA microspheres after oral administration to rat.

The purpose of the current study was to assess the feasibility of microspheres from biocompatible polymer for oral bioavailability (BA) enhancement of potent sulfonamide- type loop diuretic- Furosemide - which used in the treatment of congestive heart failure, caused edema, cirrhosis, renal disease and as an adjunct in acute pulmonary edema. The comparatively poor and inconstant BA of furosemide, which occurs site-specifically in the stomach and upper small intestine, has been ascribed to the poor dissolution of furosemide. In attempt to enhance the drug BA, poly (dl-lactic-co-glycolic acid) (PLGA) microspheres of furosemide were obtained using solvent-evaporation method and the carrier characteristics were investigated subsequently. The in vivo performance of optimum formulation was assessed by pharmacokinetic evaluation of drug after orally administration of free and loaded in microspheres to rats (4 mg/Kg). For this reason, the concentration of drug in plasma was measured by a new developed and sensitive method of HPLC. Acceptable drug loading and encapsulation efficiency of microspheres were obtained to be 70.43 and 85.21 %, respectively. Microspheres provided improved pharmacokinetic parameters (Cmax = 147.94 ng/ml, Tmax = 1.92 hr) in rats as compared with pure drug (Cmax = 75.69 ng/ml, Tmax = 1.5 hr). The obtained AUC of drug in microsphere was 10 fold higher than of the free drug. The results showed that the prepared microspheres successfully improved BA of the poorly water-soluble drug effectively.

Meta-analysis of supplemented Zhenwu decoction for treating congestive heart-failure

The paper was to systematically evaluate the clinical efficacy of supplemented Zhenwu decoction for treating congestive heart-failure. Three foreign language databases including the Cochrane Library, PubMed, EMbase and four Chinese databases including CBM, CNKI, VIP and Wanfang Database were retrieved from their establishment to July 2016 for all randomized control trials(RCTs) on supplemented Zhenwu decoction in treatment of congestive heart-failure. The references in the included RCTs were also traced. Literature selection and information extraction was completed and screened by two independent reviewers, and Meta-analysis was performed by using RevMan 5.3 software. Totally 13 clinical RCTs were included in this study, involving 982 patients. Meta-analysis results showed that as compared with western medicine alone, the total effective rate of heart function could be improved by applying supplemented Zhenwu decoction based on the western medicine[RR=1.16, 95%CI (1.10, 1.22)], with increased ejection fraction[MD=7.12, 95%CI= (3.98,10.27)], increased cardiac activity index[MD=6.92, 95%CI (5.21, 8.62)], increased stroke volume [MD=11.18, 95%CI (6.04, 16.33)], and increased heart index[MD=0.50, 95%CI (-0.29, 1.30)]. Supplemented Zhenwu decoction combined with routine treatment could improve the clinical symptoms of congestive heart-failure. However, due to the low quality in methodology and reports as well as small sample size of included RCTs in this study, more randomized double-blind trials with a large sample size are still required to verify the efficiency of supplemented Zhenwu decoction for treating congestive heart-failure.

In this issue - September 2016: Portable negative pressure wound therapy for skin grafts in dogs · Wellness testing in small animals · Effects of pimobendan on myocardial perfusion and pulmonary transit time in dogs · Rispens CVI988 vaccine virus and Marek's disease virus in poultry · A field study of ovulation in oestrus mares · Post-weaning growth of beef

In this issue - September 2016: Portable negative pressure wound therapy for skin grafts in dogs · Wellness testing in small animals · Effects of pimobendan on myocardial perfusion and pulmonary transit time in dogs · Rispens CVI988 vaccine virus and Marek's disease virus in poultry · A field study of ovulation in oestrus mares · Post-weaning growth of beef

Effect of Chronic Furosemide on Salt and Water Intake of Ponies

Furosemide is used acutely in racehorses and chronically for treatment of edema and congestive heart failure, but the behavioral effects on horses of chronic administration of this drug have not been studied. The objectives of this study were to measure salt and water intake as well as sodium and water losses in ponies treated chronically with furosemide. The salt and water intake of ponies was measured daily for 3 weeks before and 3 weeks during treatment with furosemide at a dose of 0.5 mg/kg/d. Fecal dry matter was measured for 9 days before and during furosemide treatment by collecting a fecal sample from each pony's stall and drying it overnight in a 100°C oven. Urine volume and urine sodium content were measured daily for three consecutive days during pretreatment, treatment, and post-treatment periods so that sodium and water status could be calculated. Sodium chloride intake increased in ponies treated daily with furosemide from 7.9 ± 2.2 (standard error of the mean) to 20.3 ± 2.4 g/d and was significantly higher than control for all weeks of treatment (P < .03). Water intake was also significantly increased from 8.9 ± 1 during the control period to 11 ± 0.7 kg/d during furosemide treatment (P < .001), and the ponies drank more water than they lost. Urine volume and urine sodium concentrations increased significantly during treatment with the diuretic, whereas urinary potassium and calcium concentrations decreased.

Exploring new scaffolds for angiotensin II receptor antagonism

Nowadays, AT1 receptor (AT1R) antagonists (ARBs) constitute the one of the most prevalent classes of antihypertensive drugs that modulate the renin-angiotensin system (RAS). Their main uses include also treatment of diabetic nephropathy (kidney damage due to diabetes) and congestive heart failure. Towards this direction, our study has been focused on the discovery of novel agents bearing different scaffolds which may evolve as a new class of AT1 receptor antagonists. To fulfill this aim, a combination of computational approaches and biological assays were implemented. Particularly, a pharmacophore model was established and served as a 3D search query to screen the ChEMBL15 database. The reliability and accuracy of virtual screening results were improved by using molecular docking studies. In total, 4 compounds with completely diverse chemical scaffolds from potential ARBs, were picked and tested for their binding affinity to AT1 receptor. Results revealed high nanomolar to micromolar affinity (IC50) for all the compounds. Especially, compound 4 exhibited a binding affinity of 199nM. Molecular dynamics simulations were utilized in an effort to provide a molecular basis of their binding to AT1R in accordance to their biological activities.

The Renal Outer Medullary Potassium Channel Inhibitor, MK-7145, Lowers Blood Pressure, and Manifests Features of Bartter's Syndrome Type II Phenotype.

The renal outer medullary potassium (ROMK) channel, located at the apical surface of epithelial cells in the thick ascending loop of Henle and cortical collecting duct, contributes to salt reabsorption and potassium secretion, and represents a target for the development of new mechanism of action diuretics. This idea is supported by the phenotype of antenatal Bartter's syndrome type II associated with loss-of-function mutations in the human ROMK channel, as well as, by cardiovascular studies of heterozygous carriers of channel mutations associated with type II Bartter's syndrome. Although the pharmacology of ROMK channels is still being developed, channel inhibitors have been identified and shown to cause natriuresis and diuresis, in the absence of any significant kaliuresis, on acute oral dosing to rats or dogs. Improvements in potency and selectivity have led to the discovery of MK-7145 [5,5'-((1R,1'R)-piperazine-1,4-diylbis(1-hydroxyethane-2,1-diyl))bis(4-methylisobenzofuran-1(3H)-one)], a potential clinical development candidate. In spontaneously hypertensive rats, oral dosing of MK-7145 causes dose-dependent lowering of blood pressure that is maintained during the entire treatment period, and that displays additive/synergistic effects when administered in combination with hydrochlorothiazide or candesartan, respectively. Acute or chronic oral administration of MK-7145 to normotensive dogs led to dose-dependent diuresis and natriuresis, without any significant urinary potassium losses or changes in plasma electrolyte levels. Elevations in bicarbonate and aldosterone were found after 6 days of dosing. These data indicate that pharmacological inhibition of ROMK has potential as a new mechanism for the treatment of hypertension and/or congestive heart failure. In addition, Bartter's syndrome type II features are manifested on exposure to ROMK inhibitors.

Congestive heart failure information extraction framework for automated treatment performance measures assessment.

This paper describes a new congestive heart failure (CHF) treatment performance measure information extraction system - CHIEF - developed as part of the Automated Data Acquisition for Heart Failure project, a Veterans Health Administration project aiming at improving the detection of patients not receiving recommended care for CHF. CHIEF is based on the Apache Unstructured Information Management Architecture framework, and uses a combination of rules, dictionaries, and machine learning methods to extract left ventricular function mentions and values, CHF medications, and documented reasons for a patient not receiving these medications. The training and evaluation of CHIEF were based on subsets of a reference standard of various clinical notes from 1083 Veterans Health Administration patients. Domain experts manually annotated these notes to create our reference standard. Metrics used included recall, precision, and the F 1 -measure. In general, CHIEF extracted CHF medications with high recall (>0.990) and good precision (0.960-0.978). Mentions of Left Ventricular Ejection Fraction were also extracted with high recall (0.978-0.986) and precision (0.986-0.994), and quantitative values of Left Ventricular Ejection Fraction were found with 0.910-0.945 recall and with high precision (0.939-0.976). Reasons for not prescribing CHF medications were more difficult to extract, only reaching fair accuracy with about 0.310-0.400 recall and 0.250-0.320 precision. This study demonstrated that applying natural language processing to unlock the rich and detailed clinical information found in clinical narrative text notes makes fast and scalable quality improvement approaches possible, eventually improving management and outpatient treatment of patients suffering from CHF.

Study of the solubility, photostability and structure of inclusion complexes of carvedilol with β-cyclodextrin and (2-hydroxypropyl)-β-cyclodextrin

Carvedilol is one of the most effective antihypertensive drugs used in the treatment of congestive heart failure. A major disadvantage of this pharmaceutical active substance is its limited solubility in water, gastric and intestinal fluids. One way to overcome this problem is the preparation of inclusion complexes. The aim of this study was to prepare the inclusion complexes of carvedilol with β-cyclodextrin (β-CD) and (2-hydroxypropyl)-β-cyclodextrin (HP-β-CD) and to investigate their physical properties. The formation of inclusion complexes with β-CD and HP-β-CD was confirmed using FTIR, 1H-NMR and XRD methods. Phase solubility studies indicate the formation of inclusion complexes in 1:2 molar ratio and the increase of carvedilol solubility. The stability constant (β2) was found to be 3.4 × 104 and 5.1 × 104 M−2 for inclusion complexes of carvedilol:β-CD and carvedilol:HP-β-CD, respectively. Photostability of carvedilol was increased after preparation of inclusion complexes with β-CD and HP-β-CD. Based on the results of this study, it can be concluded that the prepared complexes of carvedilol improve the solubility and stability of carvedilol and give it an advantage to be applied for the design of new pharmaceutical formulations.

Baroreflex Activation Therapy in Congestive Heart Failure: Novel Findings and Future Insights

Congestive heart failure is characterized by hemodynamic and non-hemodynamic abnormalities, the latter including an activation of the sympathetic influences to the heart and peripheral circulation coupled with an impairment of baroreceptor control of autonomic function. Evidence has been provided that both these alterations are hallmark features of the disease with a specific relevance for the disease progression as well as for the development of life-threatening cardiac arrhythmias. In addition, a number of studies have documented in heart failure the adverse prognostic role of the sympathetic and baroreflex alterations, which both are regarded as major independent determinants of cardiovascular morbidity and mortality. This represents the pathophysiological and clinical background for the use of carotid baroreceptor activation therapy in the treatment of congestive heart failure. Promising data collected in experimental animal models of heart failure have supported the recent performance of pilot small-scale clinical studies, aimed at providing initial information in this area. The results of these studies demonstrated the clinical safety and efficacy of the intervention which has been tested in large-scale clinical studies. The present paper will critically review the background and main results of the published studies designed at defining the clinical impact of baroreflex activation therapy in congestive heart failure patients. Emphasis will be given to the strengths and limitations of such studies, which represent the background for the ongoing clinical trials testing the long-term effects of the device in heart failure patients.

Vein of Galen Aneurysmal Malformation in a Neonate: A Case Report

Vein of Galen aneurysmal malformation (VGAM) is a rare congenital malformation, accounting for less than 1% of cerebrovascular abnormalities. The majority of reported cases have been associated with congestive heart failure (CHF) in the neonatal period. Herein, we present a case of VGAM, diagnosed at 37 weeks of gestation during the intrauterine life Case report: A full-term female newborn presented with severe CHF at two days of age. The patient's peripheral pulses were bounding in all four extremities. The first heart sound appeared to be normal, while the second had an accentuated pulmonic component. A systolic murmur (grade 3/6), best heard in the pulmonary area, was reported, and a cranial bruit was sought and found. The echocardiography showed evidence of right ventricular hypertrophy, while the chest X-ray indicated cardiomegaly with increased pulmonary vascularity. Moreover, echocardiography revealed dilation of the right heart chambers, a patent foramen ovale, severe tricuspid regurgitation, as well as a moderate-sized secundum atrial septal defect and a patent ductus arteriosus with right-to-left shunting. Transcranial ultrasound and contrast-enhanced CT scan of the brain detected a vein of Galen malformation. Magnetic resonance venography confirmed VGAM and identified the vessels feeding the aneurysm. Postnatal management included aggressive medical treatment of CHF. Transarterial embolization of the vessels feeding the aneurysm was suggested. However, the newborn succumbed to her disease on the following day. Conclusion: VGAM, which is a rare cause of cyanosis and heart failure in newborns, can be clinically diagnosed via proper strategies. However, extensive distribution of aneurysm usually precludes surgical management and endovascular treatment.

Effect of transplantation of cord blood total nucleated cells on the manifestation and prognosis of refractory congestive heart failure

The results of a prospective non-randomized observation study without control group to assess the course of heart failure in patients who underwent of cord blood total nucleated cells (CB TNCs) transplantation combined with traditional drug therapy have been presented.&#x0D; Materials. The study included 20 patients with congestive heart failure (CHF) IIA-IIB stage, functional class III-IV by the NYHA. CB TNCs transplantation was performed by a single intravenous dose of cell product "Cryopreserved human cord blood". Before and 1, 3, 6 and 9 months after CB TNC transplantation patients underwent echocardiographic study, the results of tests with the 6-minute walk determined exercise tolerance. The concentration of brain natriuretic peptide precursor (NT-proBNP) in blood was determined. The cardiovascular death risk was calculated using the scale MAGGIC.&#x0D; Results. Initial patients’ status was characterized by the presence of severe heart failure with reduced contractility of the myocardium and increased risk of 1- and 3-year death. Traditional conservative therapy (beta blockers, ACE inhibitors, diuretics) was not effective. After CB TNC transplantation there was registered a significant improvement of general condition of patients, an increase in exercise tolerance and, therefore, reduce of HF functional class by NYHA (before transplantation average FC was 3.2, in the post-transplant period – from 2.1 to 2, 8). Also after TNCs transplantation levels of biochemical markers of HF significantly decreased (before CB TNCs transplantation the level of NT-proBNP was 2370.3 ± 448.9 pg/mL, after CB TNCs transplantation – from 1198,6 ± 396,3 to 2300,7 ± 403,0 pg/mL ) and the same was estimated death risk from HF (1-year – 10.1-37.4 %, 3 years - 9.1-42.3 % relative to the data of the initial state). Reduced HF manifestations after CB TNCs transplantation allowed to reduce significantly the diuretics dose.&#x0D; Conclusion. Thus, transplantation of cord blood total nucleated cells in complex treatment of congestive heart failure has led to a greater efficiency of therapy and a significant reduce of CHF manifestations in patients.

Chronic ventricular assist device support: surgical innovation.

Ventricular assist device (VAD) therapy is currently one of the fastest-developing fields in cardiac surgery. Consistently improved technology, research, and gain of clinical experience have established VADs as an important option for the treatment of congestive heart failure. During the past year, novel devices and less invasive surgical procedures have been revolutionizing this field. The purpose of this manuscript is to review these innovations with special emphasis on device-related surgery. Device miniaturization has enabled less invasive VAD surgery, excluding the need for full sternotomy. Recent data show that intrahospital survival rates following less invasive VAD implantation are surpassing 90%. Secondly, two new devices, Heartmate 3 and MVAD, are being applied and tested for clinical application. In this context, the Heartmate 3 CE mark study recently concluded with excellent outcomes and without any pump thrombosis or device malfunctions. The first clinical results of the newest generation of VADs are very promising compared with old-generation devices. Furthermore, less invasive surgery is becoming a standard for the implantation, exchange, or explantation of left VADs. The joint venture of improved technology and innovative surgical techniques will push this field forward to even better outcomes and reduced complication rates.

Using a self-care management tool to improve self-care and quality of life in patients with congestive heart failure

Self-management is a primary goal for multiple chronic diseases and particularly for Congestive Heart Failure (CHF). Currently, treatment for CHF emphasizes relieving symptoms through teaching patients how to better care for themselves. Patients who take an active role in self-care are more independent; feel more able to manage their disease and experience better psychological outcomes. However, the research focused on self care-management intervention in heart failure patients in Egypt is very inadequate. Thus, this study aims to first explore the self-care management learning needs among patients with CHF, then secondly assess the effects of a self-care-management tool on self-care adequacy and quality of life (QOL) among this group of patients and thirdly identify patient opinions regarding the instructional developed tool. The research design encompasses the two designs of descriptive and quasi-experimental pretest-posttest study. A convenient sample of 256 patients with congestive heart disease was employed for the survey group in the assessment phase of the study. From this sample, 30% were then randomly assigned to use the developed instructional tool as the experimental group. Two tools were used for data collection. The first was the Heart Failure Self-Care Management Questionnaire (HFSCMQ) which included two parts: the Self-Care Heart Failure Index which was developed by Riegel et al., in 2009, and the Minnesota Living with Heart Failure Questionnaire (MLHFQ) that was developed by Rector T, in 1986. The second tool was a patient feedback opinionnaire which was developed by the researchers to determine patient’s feedback after using the developed tool. Results for the survey group revealed observed inadequate self-care management as perceived by patients with CHF involving self-care maintenance, self-care management and self-care confidence elements, as well as poor QOL detection. Results for the experimental group showed that the CHF patient’s perceptions about self-care management with its components were improved before and after use of the developed instructional tool in the second and third assessments. As well, the QOL was slightly improved as perceived by them. This proves that the self-care management tool may be effective as a self-learning reference among Egyptian CHF patients. In conclusion, instructional health education materials, particularly for patients with chronic illnesses such as CHF, are essential nursing interventions to improve patient self-care management literacy and the QOL. Furthermore, the planning, developing, and implementing of different health instructional materials for patient teaching has become a necessary scheme for nurses to improve their practice in exploring innovative roles in the health education field and activate these roles in different health specialties.

Randomized pilot trial comparing tolvaptan with furosemide on renal and neurohumoral effects in acute heart failure.

AimsLoop diuretics are first‐line medications for congestive heart failure (CHF); however, they are associated with serious adverse effects, including decreased renal function, and sympathetic nervous and renin–angiotensin system activation. We tested whether tolvaptan, a vasopressin V2‐receptor antagonist, could reduce unfavourable furosemide‐induced effects during CHF treatment.Methods and resultsSixty patients emergently hospitalized owing to CHF‐induced dyspnea were randomly assigned to receive either 40 mg intravenous furosemide daily or 7.5 mg oral tolvaptan for 5 days after admission. Both groups also received intravenous carperitide and canrenoate potassium. As results, baseline patient characteristics were similar between the furosemide (n = 30) and the tolvaptan (n = 30) groups, with no significant difference in 5 day urine volume or fluid balance. Brain natriuretic peptide and body weight improvements were similar between groups. However, serum creatinine (Cr) level did not increase, and the incidence of worsening renal function was significantly lower in the tolvaptan group. Consequently, the Cr increase to gain 1000 mL urine was 2.5‐fold lower in the tolvaptan group. Furthermore, the blood urea nitrogen (BUN)/Cr ratio significantly decreased in the tolvaptan group, suggesting that renal perfusion was preserved, and urea reuptake and passive water reabsorption were suppressed following tolvaptan treatment. Although catecholamine improvements after treatment were not significantly different, plasma renin activity was enhanced in the furosemide group.ConclusionsAs compared with furosemide, tolvaptan in patients with acute heart failure is associated with comparable decongestion, better preservation of renal function and less activation of renin–angiotensin system. (UMIN 000014134).

Complete atrioventricular block improved by balloon aortic valvuloplasty for severe aortic stenosis: Usefulness of sheathless technique in the retrograde approach

An 86-year-old man was admitted to our hospital for treatment of congestive heart failure with severe aortic stenosis and advanced atrioventricular (AV) block. Despite pharmacological therapy, he developed complete AV block and resultant acute pulmonary edema requiring temporary pacing and tracheal intubation. We urgently performed retrograde balloon aortic valvuloplasty (BAV) with a sheathless technique. The AV block disappeared soon after the procedure; this was probably attributable to the correction of relative myocardial ischemia, obtained by BAV. Thus, he successfully recovered from a critical condition.<Learning objective: It is widely accepted that balloon aortic valvuloplasty (BAV) dramatically reduces the systolic pressure gradient across the stenotic aortic valve, but the other important hemodynamic point is that it increases the coronary perfusion pressure by raising the diastolic blood pressure, both of which contribute to improving the imbalance between myocardial oxygen demand and supply. And the sheathless technique in retrograde BAV, although not yet popular, is less invasive and may be promising in urgent clinical situations.>

Abstract P6-11-03: A cost effectiveness analysis of baseline left ventricular function assessment for breast cancer patients undergoing anthracycline chemotherapy

Abstract Background: It is unclear if all breast cancer (BC) patients require baseline left ventricular function (LVEF) assessment prior to anthracycline based chemotherapy (ABC), and the approach is variable in clinical practice. Our objective is to determine the cost effectiveness of obtaining a baseline LVEF assessment prior to (neo) adjuvant ABC in clinical practice. Methods: We performed a retrospective analysis of the Yale Equilibrium Radionuclide Angiography (ERNA) database for 701 breast cancer patients who had a baseline ERNA scan prior to systemic therapy for an initial diagnosis of stages I-IV BC between July 2003 and May 2013. We found that 14 of 701 (2%) patients had a baseline LVEF &amp;lt; 50%. Age, pre-existing cardiac risk factors and coronary artery disease did not predict an abnormal baseline LVEF &amp;lt;50 %. To evaluate the benefit of obtaining a baseline echocardiogram or ERNA before ABC, we considered the screening scenario in which BC patients with a baseline LVEF &amp;lt; 50% on screening echocardiogram are treated with a second (2nd) generation non-ABC and those with baseline LVEF ≥ 50% receive a third (3rd) generation ABC, and compared this with a non-screening scenario with uniform 3rd generation ABC treatment for all patients who do not have a baseline echocardiogram. We used Adjuvant Online to obtain estimates of the disease free (DFS) and overall survival (OS) for a 3rd generation ABC regimen vs a 2nd generation non-ABC regimen for 50 year old patients with a T2N1 hormone receptor positive BC. We implemented these oncologic clinical outcomes (in addition to cardiotoxicity-related clinical outcomes, costs of screening echocardiogram and treatment of congestive heart failure (CHF), quality of life metrics, as reported in the literature) into a simplified decision-analytic cost-effectiveness analysis that accounts for the different disease states and their associated costs and quality of life outcomes. Results: Assuming that 20% of the unscreened patients with a LVEF &amp;lt; 50% will develop CHF if treated with ABC regimen without management of baseline cardiac dysfunction, the base case incremental cost effectiveness ratio (ICER) was determined to be 18,520 $USD/QALY. Sensitivity analysis suggested that the cost-effectiveness of baseline LVEF assessment is primarily driven by the prevalence of patients with LVEF &amp;lt; 50%, the incidence of CHF in this high-risk patient group if treated with ABC regimen, and time to CHF development. While our analysis did not reveal risk factors predictive of low baseline LVEF, our model's dependence on prevalence of LVEF &amp;lt; 50% demonstrates the importance of risk factor stratification. A hypothetical predictive marker which enriches the prevalence of an abnormal baseline LVEF 5-fold to 10% would result in a cost-effectiveness of 10,990 $USD/QALY. The model is less sensitive to the cost of baseline echocardiogram testing. Conclusion: Baseline LVEF assessment was found to be cost-effective under a willingness-to-pay threshold of $50,000/QALY. Our sensitivity analysis suggests that risk factor-guided LVEF baseline LVEF screening may increase the number of high-risk patients in the treatment population, thus further increasing the cost-effectiveness of baseline LVEF assessment. Citation Format: Safonov A, Hatzis C, Stratton J, Gross CP, Russell R, Pusztai L, Abu-Khalaf MM. A cost effectiveness analysis of baseline left ventricular function assessment for breast cancer patients undergoing anthracycline chemotherapy. [abstract]. In: Proceedings of the Thirty-Eighth Annual CTRC-AACR San Antonio Breast Cancer Symposium: 2015 Dec 8-12; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2016;76(4 Suppl):Abstract nr P6-11-03.