Therapy of congestive heart failure in elderly persons

LVEF should be measured in all elderly persons with CHF Underlying causes and precipitating causes of CHF should be treated. Persons with CHF associated with abnormal LVEF should be treated with a low sodium diet, diuretics, and ACE inhibitors. If CHF persists, digoxin should be added. If CHF still persists, isosorbide dinitrate plus hydralazine should be added. If CHF still persists, a beta blocker should also be added. However, calcium channel blockers should not be used. Persons with CHF associated with normal LVEF should be treated with a low sodium diet, diuretics, and ACE inhibitors. If CHF persists, a beta blocker, isosorbide dinitrate plus hydralazine, or a calcium channel blocker should be added to the therapeutic regimen. If sinus rhythm is present, digoxin should not be used. Persons with CHF and abnormal or normal LVEF unable to tolerate ACE inhibitors should be treated with losartan.     

Captopril and spironolactone therapy for refractory congestive heart failure

Short- and long-term clinical effects of the angiotensin-converting enzyme (ACE) inhibitor captopril in severe congestive heart failure (CHF) were evaluated during a 3-year open study of 124 inpatients with New York Heart Association (NYHA) functional class III or IV CHF refractory to treatment with cardiac glycosides and high doses of loop diuretics. Captopril was added to each patient's regimen, which comprised combinations of furosemide (124 patients), digitalis (117 patients), and spironolactone (90 patients). By the end of the first month of captopril administration, improvement in NYHA functional class was seen in 89 patients (72%). During the first year of captopril treatment, the number of hospital admissions and hospital days declined significantly (p < 0.001) and functional class improved significantly (p < 0.001). Although most patients tolerated captopril well, 44% experienced hypotension, which in 10% of patients necessitated termination of captopril therapy. Although mean serum potassium levels tended to increase, serious hyperkalemia did not occur. After 1 year, a subset of 30 patients who had not initially received spironolactone deteriorated clinically and manifested increasing urinary aldosterone levels. Hypotension precluded increasing the captopril dose, but introduction of spironolactone improved clinical status in this cohort. The results suggest that rational therapy for severe CHF includes addition of the aldosterone antagonist spironolactone to low doses of captopril (or another ACE inhibitor) and high doses of loop diuretics, provided renal function is adequate.     

Treatment of congestive heart failure with beta-methyldigoxin (lanitop)

Methylated Digoxin preparation--beta-Methyldigoxin (Lanitop) was used in 50 patients with congestive heart failure of different etiology (tablets of 0.3--0.6 mG per day). Its employment proved very effective in the treatment of congestive heart failure. It is not contraindicated to patients with chronic coronary insufficiency with underlying athrosclerotic cardiosclerosis with signs of congestive circulatory insufficiency. Side-effects of beta-Methyldigoxin are mild and noted rather seldom.     

Managed care and outcomes of hospitalization among elderly patients with congestive heart failure

123I-radiolabeled metaiodobenzylguanidine (123I-MIBG) cardiac imaging has been used to evaluate the distribution of sympathetic nervous system (SNS) in the heart. Different heart diseases have shown impaired cardiac SNS distribution as reflected by MIBG activity. The aim of this study was to assess the cardiac distribution of SNS in normal subjects, using MIBG imaging. Ten normal subjects (1 male and 9 females, mean age 46 +/- 9 years) with no cardiac abnormalities underwent myocardial 123I-MIBG scintigraphy, Tc-99m methoxyisobutylisonitrile (MIBI) cardiac perfusion imaging and equilibrium radionuclide angiography (RNA). Regional myocardial MIBG and MIBI activities were quantitatively evaluated using a region of interest analysis. For this purpose, the left ventricle was divided into 6 myocardial regions as anterior, apical, inferior, septum, lateral and posterolateral. In particular, myocardial MIBG and MIBI activities were measured as myocardium to mediastinum ratio. Regional left ventricular function was assessed by RNA. Myocardial MIBG uptake was homogeneous in anterior (2.2 +/- 0.5), inferior (2.5 +/- 0.7), septal (2.4 +/- 0.4), lateral (2.3 +/- 0.4), and posterolateral (2.3 +/- 0.4) regions. Conversely, MIBG uptake was significantly lower in the apical region (1.9 +/- 0.3) compared to all other left ventricular segments (p < 0.05). Regional myocardial perfusion, as measured by MIBI uptake, was homogeneous in all regions. No regional left ventricular wall motion abnormalities were observed by RNA. In conclusion, our data suggest that a decreased MIBG uptake may be observed in the left ventricular apical region of normal subjects reflecting reduced sympathetic innervation of the apex. This finding is not related to myocardial perfusion or wall motion abnormalities. The knowledge of cardiac sympathetic innervation in normal subjects may be helpful to assess SNS abnormalities in heart disease.     

Pulmonary function tests in patients with congestive heart failure: effects of medical therapy

In a group of 13 patients with severe heart failure, both forced vital capacity (FVC) and forced expiratory volume in 1 s (FEV1) significantly improved after intensive medical therapy (FVC: from 77 +/- 17 to 92 +/- 20%, p < 0.001; FEV1: from 65 +/- 15 to 81 +/- 15%, p < 0.001) in the absence of change in M-mode echo cardiac dimension and left ventricular systolic function; on the other hand, a change of indices of left ventricular filling by Doppler transmitral flow was documented (E/A ratio: from 3.6 +/- 1.2 to 1.65 +/- 1.5, p < 0.01; early filling deceleration time: from 94 +/- 39 to 178 +/- 78 ms, p < 0.01), indicating a reduction of pulmonary capillary pressure; this probably positively affected pulmonary interstitial edema and bronchial wall congestion, thus enhancing pulmonary function.     

Efficacy of mononitrate retard therapy in patients with advanced congestive heart failure

To determine the efficacy of mononitrate retard therapy in congestive heart failure 54 pts (42 males and 12 females, aged 67.2 +/- 8.7 yrs.) with NYHA functional class 1-3 and left ventricular ejection fraction less than 40% were investigated. Clinical examination, exercise treadmill test (ETT), ecg holter monitoring and echocardiography (echo-2D) were performed before and after 4 weeks of therapy with Olicard 40 mg Retard. 4 weeks treatment with mononitrate improved clinical parameters. The shift to lower functional NYHA class was observed in 12 cases (p < 0.01). Number of anginal pains per week was reduced from average 3.15 to 1.55 (p < 0.01). Mononitrate therapy improved exercise tolerance during ETT. Exercise time increased from 424 +/- 168 to 568 +/- 143 sec. (p < 0.001) as well as total workload in METS (3.6 +/- 1.4 vs. 4.9 +/- 1.9, p < 0.001). The time to 0.1 mV ischemic ST segment depression was extended from 215 +/- 149 to 357 +/- 173 sec. (p < 0.01). Holter monitoring revealed moderate increase in heart rate and significant reduction of ventricular arrhythmia (p < 0.05). No changes in systolic and diastolic echo-2D parameters were observed.     

Relation of Doppler transmitral flow patterns to functional status in congestive heart failure

We analyzed the relation of Doppler transmitral flow patterns and New York Heart Association (NYHA) classification in 60 consecutive patients with heart failure (44 men and 16 women; mean age 58 +/- 13 years) with left ventricular ejection fraction of < 40 percent. Of the study population, 40 patients with mild to moderate heart failure underwent symptom-limited exercise testing. The relation of transmitral flow pattern and exercise tolerance was also analyzed. Doppler echocardiography was performed in all patients. The patients were subdivided into nonrestrictive and restrictive groups according to the pattern. The univariate analysis showed a relation for left ventricular ejection fraction (p = 0.01 by analysis of variance testing) and transmitral flow pattern (p = 0.0003 by chi-squared test) with NYHA classification. When the multivariate regression analysis was performed, only the restrictive pattern by Doppler emerged as an independent determinant of the advanced NYHA class (p = 0.005). In mild to moderate congestive heart failure, patients with nonrestrictive pattern exercised significantly longer than those with the restrictive pattern by an average of 133 seconds (p = 0.003) despite comparable reductions in ejection fraction. Thus the restrictive transmitral flow pattern by Doppler is a noninvasive marker for severe symptoms and diminished exercise tolerance in heart failure patients.     

Ace inhibitors: treatment of congestive heart failure

Nasal passage geometry was measured by acoustic rhinometry in 8 healthy medical students (5 males and 3 females, 21-29 years old; mean age 24 years) after 6 min in different postures of head and body. The minimum cross-sectional area (A-min) and volume between the nostril and 7 cm posteriorly were measured on both sides. When changing from sitting to horizontal the total airway dimension (i.e., the sum of A-min for the two sides) decreased by about 16% (Mean +/- SD = 0.19 +/- 0.14 cm2), and when standing up it increased by about 12% (0.14 +/- 0.13 cm2). A-min seemed more sensitive than volume to detecting postural changes. Including the variation between the cavities, the coefficient of variation (CV = SD/Mean) for area was 24.8 +/- 6.7 and for volume 22.4 +/- 6.4 for the 8 subjects. For the total nasal airway passage the corresponding figures were 12.9 +/- 3.9 and 10.9 +/- 5.5. These figures are considerably higher than for subjects measured only in the sitting position under comparable circumstances. In conclusion, our findings indicate a composite response of the nasal cavity mucosa to both systemic (hydrostatic) and local conditions, probably induced by vascular and cutaneous reflexes. These factors must be taken into account in studies of environmental, clinical, and pharmacological conditions.     

NSAIDs associated with increased risk of congestive heart failure in elderly patients taking diuretics

BACKGROUND: Both diuretics and nonsteroidal anti-inflammatory drugs (NSAIDs) are widely used, in particular among the elderly. The use of NSAIDs may decrease the efficacy of diuretics and induce congestive heart failure (CHF) in patients treated with diuretics. OBJECTIVE: To investigate the risk of CHF associated with combined use of diuretics and NSAIDs in patients older than 55 years. METHODS: We conducted a study in a base cohort of 10,519 recipients of diuretics and NSAIDs identified in the PHARMO database during the period from 1986 through 1992. The incidence density of hospitalizations for CHF during exposure to both diuretics and NSAIDs (index) was compared with that during exposure to diuretics only (reference). RESULTS: We found an overall increased risk of hospitalization for CHF during periods of concomitant use of diuretics and NSAIDs compared with use of diuretics only (crude relative risk, 2.2; 95% confidence interval, 1.7-2.9). After adjusting for cofactors including age, sex, history of hospitalization, and drug use, a 2-fold increased risk remained (relative risk, 1.8; 95% confidence interval, 1.4-2.4). CONCLUSION: Use of NSAIDs in elderly patients taking diuretics is associated with a 2-fold increased risk of hospitalization for CHF, especially in those with existing serious CHF.     

Treatment of end-stage renal failure after heart transplantation

BACKGROUND: Five to 10% of heart-transplant recipients develop end-stage renal failure (ESRF). Little is known about the outcome of these patients under renal replacement therapy. METHODS: We conducted a retrospective study in 16 men (mean age 52.8+/-7.4 years at heart transplantation) who developed ESRF 5.3+/-2.1 years later. Results. Haemodialysis (HD) was the first-line treatment (mean Kt/V 1.35+/-0.4). Vascular access was unsuccessful in six patients (37.5%) due to peripheral arteriopathy and they were treated with tunnelled catheters for an average 15 months without bacterial infection. Mean weight was 68.4+/-10 kg at onset of HD and 61.7+/-9 kg one month later. Despite this reduction in extracellular overload, one antihypertensive drug was required in 75% of patients and two drugs in 12.5%. One patient tolerated automated peritoneal dialysis (PD) for 16 months (weekly Kt/V 2.1) despite persistent anuria. Renal transplantation (RT) was contraindicated in eight patients because of aortoiliac arteriopathy (n=5), poor general status (n=2), or ischaemic heart disease (n=1). RT was performed in eight patients with no acute episode of heart or renal graft rejection. There were no serious infectious complications. Three months after RT, mean serum creatinine was 115 micromol/l. One patient developed post-transplant lymphoproliferative disorder 3.5 months after RT and was successfully treated with transplant nephrectomy. Sudden death occurred in two patients 18 and 33 months after RT. Overall patient survival was 100, 78, and 59%, 1, 2 and 3 years after HD onset respectively. Using a time-dependent variable, the Cox model analysis demonstrated that heart-transplant recipients with ESRF have a relative risk of death 3.2 times higher than those without ESRF (95% CI = 1.3-7.8). CONCLUSIONS: HD, PD, and RT can be useful for the treatment of ESRF after heart transplantation. After initiating HD, patient survival is nearly the same as that reported in patients in Europe undergoing HD for other causes. But ESRF seems to reduce life expectancy in heart-transplant recipients.     

Carvedilol: the new role of beta blockers in congestive heart failure

The prognosis remains poor for patients with congestive heart failure (CHF), despite reduced mortality rates resulting from the addition of angiotensin converting enzyme inhibitors to traditional treatment regimens. Because much of the myocardial damage that occurs in patients with CHF may be related to sympathetic activation, interest in the use of beta blockers has grown. Recent studies have shown the benefits of beta blocker therapy in many patients with heart failure. Carvedilol, the first beta blocker labeled in the United States specifically for the treatment of heart failure, has been shown to improve left ventricular ejection fraction and may reduce mortality.     

Beta-blocker therapy of severe congestive heart failure in infants with left to right shunts

We report on the clinical and neurohumoral effects of adding low-dose propranolol to conventional therapy with digoxin and diuretics in 6 infants with severe congestive heart failure due to large left-to-right shunts. A significant decrease in heart failure scores and a decrease of the highly activated renin-angiotensin-1 aldosterone system by approximately 70% strongly suggests a beneficial effect of this new therapeutic approach.     

Treatment of patients admitted to the hospital with congestive heart failure: specialty-related disparities in practice patterns and outcomes

OBJECTIVES: This study sought to define specialty-related differences in the care and outcome of patients admitted to the hospital with congestive heart failure (CHF). BACKGROUND: Congestive heart failure is the leading diagnosis-related group (DRG) discharge diagnosis in the United States and accounts for an estimated annual hospital cost in excess of $7 billion. The clinical impact of aggressive CHF management and the importance of the subspecialist in guiding this care have not been evaluated. METHODS: To define differences in physician practice patterns, we performed a chart review of consecutive patients admitted to a university teaching hospital with a primary DRG discharge diagnosis of CHF. We compared treatment and outcome of patients cared for by a generalist (n = 160) and those whose care was guided by a cardiologist (n = 138) during their index hospital period with CHF and over the next 6 months. RESULTS: At our institution, > 50% of patients admitted to the hospital with CHF cared for by generalists alone had minimal (New York Heart Association functional class I or II) symptoms, compared with < 15% of those cared for by a cardiologist (p < 0.01). Although generalists' patients underwent significantly fewer in-hospital diagnostic tests and had shorter lengths of stay, they had a 1.7-fold increased risk of readmission for CHF within 6 months (p < 0.05). Six-month cardiac and all-cause mortality were not significantly different between the groups. The type of physician caring for the patient and a history of diabetes, previous CHF or myocardial infarction were independent predictors of readmission for CHF. CONCLUSIONS: Involvement of a cardiologist in the care of patients admitted to the hospital with CHF is associated with increased use of diagnostic testing, longer hospital stays and improved clinical outcome. These results substantiate practice guidelines that suggest a role for cardiologists in the care of symptomatic patients with CHF.     

Postnephrectomy arteriovenous fistula--surgical experience of a complicated case by renal dysfunction and congestive heart failure

Postnephrectomy arteriovenous fistula is a rare complication. Twenty nine years after the left nephrectomy due to renal tuberculosis, a 71-year-old male who had suffered from heart and renal failure was diagnosed as postnephrectomy arteriovenous fistula. Ligation of left renal artery and division of left renal vein were performed. Although CVP improved from 30 to 14 cmH2O after operation, cardiac function did not show remarkable improvement, and we were necessitated to introduce hemodialysis from the third week after operation. It is important to bear in mind this complication in order to make early diagnosis and treatment.