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J M Nicklas

Publications and source records attributed to J M Nicklas.

At least 19 recordsLinked to original sources
PubMed2001

Guideline for the management of heart failure caused by systolic dysfunction: part II. Treatment.

Several large clinical trials conducted over the past decade have shown that pharmacologic interventions can dramatically reduce the morbidity and mortality associated with heart failure. These trials have modified and enhanced the therapeutic paradigm for heart failure and extended treatment goals beyond limiting congestive symptoms of volume overload. Part II of this two-part article presents treatment recommendations for patients with left ventricular systolic dysfunction. The authors recommend that, if tolerated and not contraindicated, the following agents be used in patients with left ventricular systolic dysfunction: an angiotensin-converting enzyme inhibitor in all patients; a beta blocker in all patients except those who have symptoms at rest; and spironolactone in patients who have symptoms at rest or who have had such symptoms within the past six months. Diuretics and digoxin should be reserved, as needed, for symptomatic management of heart failure. Other treatments or treatment programs may be necessary in individual patients.

Adrenergic beta-Antagonists↗
PubMed2001

Prognostic importance of marital quality for survival of congestive heart failure.

Mounting evidence indicates that social support is associated with better outcomes of cardiovascular disease and reduced all-cause mortality. Much less is known about the specific contribution of marital functioning to these outcomes, and the potential prognostic significance of marital quality for congestive heart failure (CHF) has not been explored. Interview and observational measures of marital quality obtained from 189 patients with CHF (139 men and 50 women) and their spouses were examined as predictors of patient survival up to 48 months after assessment and compared with prediction based on illness severity (New York Heart Association [NYHA] class). Four-year survival rates were 52.5% and 68% for male patients and female patients, respectively. In Cox regression analyses, a composite measure of marital quality predicted 4-year survival as well as the patient's concurrent NYHA class did (both p <0.001). Adjusting for CHF severity did not diminish the prognostic significance of marital functioning, and prediction of survival from marital quality appeared stronger for female than for male patients. Thus, when marital quality and NYHA class are considered jointly, they both make independent, statistically significant contributions to the prediction of patient mortality.

Adult↗
PubMed2001

Guideline for the management of heart failure caused by systolic dysfunction: Part I. Guideline development, etiology and diagnosis.

Over the past decade, the conceptual understanding of heart failure has changed significantly. Several large clinical trials have demonstrated that pharmacologic interventions can dramatically reduce the morbidity and mortality associated with heart failure. These trials have extended the therapeutic paradigm for treating heart failure beyond the goal of limiting congestive symptoms of volume overload. This two-part article presents an evidence-based guideline to assist primary care physicians in evaluating and treating patients with heart failure. Part I describes the new paradigm of heart failure and offers guidance for diagnostic testing. Part II presents a treatment guideline.

Evidence-Based Medicine↗
PubMed2000

Acute endothelin A receptor blockade causes selective pulmonary vasodilation in patients with chronic heart failure.

BACKGROUND: Elevated plasma endothelin-1 (ET-1) levels in patients with chronic heart failure correlate with pulmonary artery pressures and pulmonary vascular resistance. ET(A) receptors on vascular smooth muscle cells mediate pulmonary vascular contraction and hypertrophy. We determined the acute hemodynamic effects of sitaxsentan, a selective ET(A) receptor antagonist, in patients with chronic stable heart failure receiving conventional therapy. METHODS AND RESULTS: This multicenter, double-blind, placebo-controlled trial enrolled 48 patients with chronic New York Heart Association functional class III or IV heart failure (mean left ventricular ejection fraction 21+/-1%) treated with ACE inhibitors and diuretics. Patients with a baseline pulmonary capillary wedge pressure >/=15 mm Hg and a cardiac index </=2.5 L. min(-1). m(-2) were randomized to 1 of 3 doses (1.5, 3.0, or 6.0 mg/kg) of sitaxsentan or placebo as an intravenous infusion over 15 minutes. Hemodynamic responses were assessed by catheterization of the right side of the heart for 6 hours. Sitaxsentan decreased pulmonary artery systolic pressure, pulmonary vascular resistance, mean pulmonary artery pressure, and right atrial pressure (P</=0.001, 0.003, 0.017, and 0.031, respectively) but had no effect on heart rate, mean arterial pressure, pulmonary capillary wedge pressure, cardiac index, or systemic vascular resistance. Plasma ET-1 levels were elevated at baseline and decreased with sitaxsentan. CONCLUSIONS: In patients with moderate to severe heart failure receiving conventional therapy, acute ET(A) receptor blockade caused selective pulmonary vasodilation associated with a reduction in plasma ET-1. Sitaxsentan may be of value in the treatment of patients with pulmonary hypertension secondary to chronic heart failure.

Cardiac Output, Low↗
PubMed2000

Transpulmonary passage of Albunex as a marker of intracardiac hemodynamics and outcome in chronic congestive heart failure.

BACKGROUND: Aggressive management to reduce pulmonary artery systolic pressure (PASP) and pulmonary capillary wedge pressure (PCWP) reduces hospitalization rates and is crucial for patients awaiting transplantation but may require periodic invasive monitoring with right heart catheterization. METHODS: The purpose of this study was to define the relation of transpulmonary passage of Albunex (Mallinckrodt Medical, St Louis, Mo) to intracardiac hemodynamics and clinical outcome in patients with chronic congestive heart failure (CHF). Patients (n = 38) with chronic CHF underwent graded dobutamine infusion (baseline, 5, 10, 20 microg/kg per minute; 5-minute stages) with 5.0 mL Albunex injected intravenously at each stage. The dobutamine dose at which Albunex appeared in the left ventricle was determined. All patients had right heart catheterization to determine PASP and PCWP. RESULTS: Transpulmonary passage of Albunex at baseline or at 5 microg/kg per minute dobutamine infusion predicted PCWP <20 mm Hg with a positive predictive value of 100% and a negative predictive value of 79%. Initial appearance of Albunex in the left ventricle at a dobutamine dose of 20 microg/kg per minute or failure to appear at any dose predicted a PCWP >20 mm Hg with a positive predictive value of 100% and a negative predictive value of 94%. No patient with Albunex passage at baseline sustained a major adverse event. Major adverse events occurred in 11 of 21 patients in whom Albunex either failed to cross or crossed the pulmonary bed at a dose of 20 microg/kg per minute of dobutamine. CONCLUSION: In patients with chronic CHF, transpulmonary passage of Albunex during dobutamine infusion can be used to predict both elevated and normal intracardiac pressures and to identify a subset of patients at high risk for an adverse outcome.

Adult↗
PubMed2000

New graphical method for evaluating gas exchange in congestive heart failure.

PURPOSE: The purpose of this study was to determine the usefulness of a new graphical method for evaluating gas exchange (GE), as applied to three common averaging techniques used during rest, exercise, and recovery in patients with congestive heart failure (CHF). METHODS: Fifty patients' resting, exercise, and recovery GE graphs were evaluated using a new graphical method to determine oxygen consumption (VO2), ventilation (VE), and respiratory exchange ratio (RER). Precision of the new method was evaluated by repeated measures using the same investigator, an additional investigator, and an untrained student. A 1-min rolling time average (RTA) updated every 20 s was used as the reference to the graphical method and the metabolic cart's computer analysis. Breath-by-breath data were evaluated using three averaging techniques, average 5 of 7 breaths (5/7), average of 8 breaths (AVG 8), and 30-s average (30-s). Differences between the computer and the graphical method were assessed by two-sided t-tests; ANOVA was used between the three investigators and also between the three averaging techniques. RESULTS: There were no significant differences of repeated measures between trained and untrained investigators. The graphical method results were significantly different than the computer results. The only difference with RTA involved computer resting values, which were also different than the graphical method. CONCLUSION: In conclusion, the graphical method may be used to standardize GE evaluation because it displays excellent intrainvestigator precision and good interinvestigator precision between experienced and inexperienced investigators. Averaging techniques less than 30 s have greater bias when using computer-derived values, although when incorporating the graphical method the averaging technique chosen has little influence on all measures.

Female↗
PubMed2000

What does ATLAS really tell us about "high" dose angiotensin-converting enzyme inhibition in heart failure?

The Assessment of Treatment with Lisinopril and Survival (ATLAS) results have been widely quoted by proponents advocating the use of "high" doses of angiotensin-converting enzyme (ACE) inhibitors for the treatment of heart failure. In ATLAS, however, the relative benefits of "high" versus "low" dose ACE inhibition were small. Intermediate doses of ACE inhibitors proven effective in previous placebo-controlled trials provide benefit that appears likely to equal or exceed the benefit from "high" dose ACE inhibition. Therefore, we recommend that physicians continue to prescribe ACE inhibitors for patients with heart failure based on the target doses used in the placebo-controlled trials and not on the "high" dose target used in ATLAS.

Angiotensin-Converting Enzyme Inhibitors↗
PubMed2000

Early spontaneous recovery of left ventricular function in patients with myocarditis.

The natural history of myocarditis is varied. We describe 6 out of a cohort of 15 consecutive patients with histopathologic evidence of myocarditis who showed a remarkable early symptomatic and spontaneous recovery of left ventricular systolic function. The left ventricular ejection fraction increased to > or = 50% at discharge, and this improvement was maintained at late follow-up. The other 9 patients, despite clinical improvement, were not thought to have spontaneous recovery. Neither clinical severity of the illness (NYHA functional class) nor left ventricular ejection fraction at presentation demonstrated any difference in the two groups. By contrast, a smaller left ventricular internal diameter at end-diastole and a smaller left atrial dimension as determined by transthoracic echocardiography were predictive of spontaneous recovery. Firstly, we confirm that the natural history of myocarditis is indeed varied with the possibility of early spontaneous recovery; secondly we suggest that left ventricular internal diameter at end-diastole and left atrial dimension may have prognostic implications in this disease.

Adult↗
PubMed1999

Diurnal variation in plasma norepinephrine in patients with heart failure.

Diurnal variation in plasma norepinephrine (PNE) levels is well documented in healthy individuals but not in patients with heart failure. Therefore, we attempted to determine variations in PNE levels over 24 hours, measured hourly, in six patients with an ejection fraction below 40% and a history of heart failure of longer than 3 months. Three controls without a history of heart failure also were evaluated. Both patients and controls had diurnal variations in PNE, with highest levels occurring during the day and lowest at night. When data in patients were evaluated by 6-hour time intervals the mean value for 6:00 A.M.-12:00 noon was approximately twice as high as 12:00 midnight-6:00 A.M. (689+/-329 vs 338+/-166 pg/ml, p<0.05, respectively). Patients also had significant peak to trough variation in PNE levels compared with controls (959+/-396 vs 386+/-84 pg/ml, p<0.02, respectively). These results suggest that significant intrapatient variations in PNE occur over 24 hours in patients with heart failure. These variations may have to be accounted for when evaluating and treating patients with heart failure.

Aged↗
PubMed1998

Pharmacokinetics of torsemide in patients with decompensated and compensated congestive heart failure.

Plasma pharmacokinetics of oral furosemide have been shown to be influenced by degree of decompensation in patients with congestive heart failure (CHF). This open-label, sequential comparison trial was conducted to determine whether CHF decompensation also alters the pharmacokinetics and pharmacodynamics of torsemide. Twelve patients with CHF, defined by either hemodynamic parameters or clinical signs and symptoms, were enrolled. On admission for treatment of their CHF, the patients were given 100 mg oral torsemide (phase A). A second dose of oral torsemide 100 mg was administered after hemodynamic parameters and clinical signs and symptoms of decompensated CHF resolved (phase B). Plasma and urine samples were collected over a 24-hour period for determination of torsemide concentrations and urine sodium. Hemodynamic measurements and physical signs and symptoms also were evaluated. During phase A, patients had significantly greater urine output and fractional sodium excretion compared with phase B. A significant increase in the area under the plasma concentration-time curve (AUC) was observed during phase B compared with phase A. However, no significant differences in maximal excretion rate of torsemide were noted between phase A and phase B. Heart failure status slightly affects the plasma pharmacokinetics of torsemide; however, this does not significantly alter the maximal urinary excretion rate of torsemide.

Area Under Curve↗
PubMed1994

Relation of neurohumoral activation to clinical variables and degree of ventricular dysfunction: a report from the Registry of Studies of Left Ventricular Dysfunction. SOLVD Investigators.

OBJECTIVES: This study examined the relation between neurohumoral activation and severity of left ventricular dysfunction and congestive heart failure in a broad group of patients with depressed left ventricular function who were not recruited on the basis of eligibility for a therapeutic trial. BACKGROUND: Previous studies have established the presence of neurohumoral activation in patients with severe congestive heart failure. It is not known whether the activation of these neurohumoral mechanisms is related to an impairment in left ventricular function. METHODS: From the 6,273 patients recruited into the Studies of Left Ventricular Dysfunction Registry (SOLVD), a subgroup of 859 patients were randomly selected, and their plasma norepinephrine, plasma renin activity, arginine vasopressin and atrial natriuretic peptide levels were correlated with clinical findings, New York Heart Association functional class, left ventricular ejection fraction and drug use. RESULTS: There was a weak but significant correlation between ejection fraction and an increase in plasma norepinephrine (rho = -0.18, p < 0.0001), plasma renin activity (rho = -0.24, p < 0.0001) and arginine vasopressin (rho = -0.12, p < 0.003). The only exception was atrial natriuretic peptide, which showed the best correlation to ejection fraction (rho = -0.37, p < 0.0001). Deterioration in functional class was associated more with increases in atrial natriuretic peptide (p = 0.0003) and plasma renin activity (p = 0.0003) and less with an increase in plasma norepinephrine. Of the clinical variables, elevated jugular venous pressure and third heart sound (S3) gallop were significantly associated with increased levels of plasma norepinephrine, plasma renin activity and atrial natriuretic peptide. We then compared the relation of neurohormones with clinical signs, functional status, ejection fraction and drug therapy and controlled for mutual interactive effects. After adjustment, a decrease in ejection fraction was still significantly related to an increase in plasma norepinephrine, plasma renin activity and atrial natriuretic peptide. In contrast, only a difference between functional classes I and III/IV was associated with an increase in plasma renin activity and atrial natriuretic peptide levels. CONCLUSIONS: Neurohumoral activation in patients with heart failure is related to severity of left ventricular functional depression, and this relation is independent of functional class or concomitant drug therapy.

Aged↗
PubMed1994

Heart failure: clinical implications of recent trials.

The frustration has been in identifying drugs that have a positive impact on cardiac performance and a negative effect on mortality. ACE inhibitors, often with diuretics and possibly with digoxin, continue to show impressive outcomes in major studies.

Angiotensin-Converting Enzyme Inhibitors↗
PubMed1991

Prospective, double-blind, placebo-controlled trial of low-dose amiodarone in patients with severe heart failure and asymptomatic frequent ventricular ectopy.

Sudden cardiac death is a common cause of mortality in patients with congestive heart failure. To determine if low-dose amiodarone could reduce sudden death among these patients, a prospective, placebo-controlled, double-blind pilot trial was conducted. One hundred one patients with ejection fractions less than 30%, New York Heart Association class III or IV symptoms, and frequent but asymptomatic spontaneous ventricular ectopy (Lown class II to V) were randomly assigned to treatment with low-dose amiodarone (400 mg/day for 4 weeks and then 200 mg/day) or placebo. Mean follow-up was 357 days (range 4 to 1009 days). Side effects were infrequent and there was no difference in the incidence of side effects between the treatment groups. The frequency of spontaneous ventricular ectopy in the group receiving amiodarone fell from 4992 +/- 1240 beats/24 hours at baseline to 1135 +/- 494 beats/24 hours after 1 month of treatment (p = 0.02) and remained low after 6 months, while there was no change in ventricular ectopy among the patients receiving placebo. Despite the reduction in ectopy, there was no improvement in mortality or decrease in the incidence of sudden death. One-year mortality by Kaplan-Meier analysis was 28% in the group receiving amiodarone and 19% in the group receiving placebo (p = NS). One-year mortality in patients with greater than 75% reduction in ventricular ectopy after 1 month of treatment was 31% versus 17% in patients with less than or equal to 75% ectopic suppression (p = NS).(ABSTRACT TRUNCATED AT 250 WORDS)

Adult↗
PubMed1991

Treatment of cardiogenic shock with the Hemopump left ventricular assist device.

A multiinstitutional study is in progress to evaluate the Hemopump in the treatment of cardiogenic shock. Fifty-three patients with refractory cardiogenic shock were selected for Hemopump assistance. The hemodynamic definition of cardiogenic shock included (1) a cardiac index of less than 2.0 L.min-1.m-2, (2) pulmonary capillary wedge pressure of greater than 18 mm Hg, and (3) a systolic blood pressure of less than 90 mm Hg or a left ventricular work index of less than 1,500 g-m.m-2.min-1. The Hemopump was successfully inserted in 41 of 53 patients (77.3%). A significant improvement in the hemodynamic status was seen during Hemopump assistance. A minimal level of hemolysis was observed. No leg ischemia was observed. The 30-day overall survival of the Hemopump group was 31.7%. Criteria establishing indications for use and clinical utility are proposed. We conclude that the Hemopump provides significant hemodynamic support of the patient in cardiogenic shock allowing for recovery from ventricular stunning in marginal ventricles, and that in select patients the Hemopump may offer a major improvement in survival over conventional therapy.

Cardiac Output↗
PubMed1991

Computer analysis of physiologic signals in a cardiovascular research laboratory.

A comprehensive computer program which provides immediate computation and feedback has been developed for data acquisition and analysis of signals in a cardiovascular animal laboratory. The system is based on a microcomputer equipped with analog-to-digital converter and supports function modules which digitize, filter, and differentiate up to 8 simultaneously sampled cardiovascular signals. The program detects, analyses, and plots incoming and averaged beats. Beat-by-beat signal averaging for each channel is performed and cardiac cycles are partitioned automatically. For each cardiac and average cycle the amplitude at 6 physiologic fiducial markers are measured and derived calculations are made. Channel vs channel plots and loop area measurements are also computed and displayed. The computer algorithms have been shown to give accurate, precise, and reproducible results when tested on canine cardiovascular data. Also, it has been demonstrated that signal averaging is an appropriate analysis technique for cardiovascular signals.

Algorithms↗