Beyond the four quadrants: the critical and emerging role of impedance cardiography in heart failure.
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Algorithms↗
Biomedical subjects
Marc A Silver
Publications and source records attributed to Marc A Silver.
Evaluation of impedance cardiography as an alternative to pulmonary artery catheterization in critically ill patients.
Invasive pulmonary artery catheterization has historically been the method of choice for the evaluation of hemodynamic status. Impedance cardiography (ICG) is an accurate, noninvasive technique to obtain hemodynamic status information without the risk and cost associated with invasive methods. The purpose of this prospective, observational study was to determine whether the availability of ICG could decrease the need for placement of a pulmonary artery catheter in critically ill patients in coronary care units. After the need for hemodynamic data was determined, ICG parameters were provided to the attending physician who then decided whether pulmonary artery catheter insertion was still necessary. Of 107 subjects enrolled in the study, 14 (13%; 95% confidence interval, 7.3%-21.0%) were judged by the treating physicians to have indications for hemodynamic monitoring. In these subjects, the provision of ICG data allowed the physician to avoid placement of a pulmonary artery catheter in 10/14 patients (71%; 95% confidence interval, 41.9%-91.6%). When ICG was utilized, clinicians reported that the information was helpful in 10/10 patients (100%; 95% confidence interval, 74.1%-100.0%) and improved outcome in 6/10 patients (60%; 95% confidence interval, 26.2%-87.8%). ICG can replace the pulmonary artery catheter in coronary care unit patients, and clinicians utilizing ICG believe it aids medical decision making and improves patient outcomes.
Acute Disease↗
Decompensated heart failure: is there a role for the outpatient use of nesiritide?
Heart failure (HF) management has seen enormous advances in the past two decades, including publication of HF management guidelines targeted at further reduction of morbidity and mortality. Nonetheless, the morbidity of HF has steadily increased and now represents one of the largest health care expenditures in this country. Because hospitalization for HF is most likely for patients with more advanced HF, they share a disproportionate burden of the hospitalization costs and will require treatment regimens beyond the current guidelines, if this burden is to be alleviated. In June 2004, a group of investigators who helped establish the natriuretic peptide treatment paradigm, met to discuss the potential role of nesiritide as an outpatient treatment option for patients with symptomatic HF who were at high risk for repeated admissions, a syndrome now described as "chronic decompensated HF." This report presents their considerations on the contribution of natriuretic peptide physiology to the amelioration of progressive left ventricular dysfunction, the therapeutic use of B-type natriuretic peptide, and its potential application to the outpatient management of acute and chronic decompensated HF. The use of outpatient IV nesiritide was considered a promising treatment option for symptomatic chronic decompensated HF patients that merits further investigation. Such an approach, once validated, should be integrated into an evidence-based HF disease management program.
Acute Disease↗
Increasing self-management skills in heart failure patients: a pilot study.
Nonadherence to medical treatment among heart failure patients is high and results in frequent exacerbations and premature death. This treatment-only pilot study examined whether a year-long group-based self-management intervention is feasible and improves self-management skills in patients with mild-to-moderate heart failure (ejection fraction < or =40% and New York Heart Association functional class I, II, or III). A total of 31 of 100 recruited patients (31%) agreed to participate. Twenty-six (84%) completed the year-long self-management program. Compared with baseline, the intervention was associated with an increase in overall self-efficacy in practicing self-management skills (p<0.001) and in four of five specific self-management skills. Patients and their group leaders also reported an increase in actual use of self-management skills (p<0.001) and in several psychosocial outcomes. The success of this pilot study suggests the need for a randomized clinical trial to test the efficacy of group-based self-management training on medical outcomes.
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Heart failure advances... going to the dogs.
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Animals↗
Current and emerging issues with B-type natriuretic peptide. Roundtable discussion.
A brief panel discussion was held on March 23, 2005, in New York City following a live symposium for primary care physicians discussing the roles of B-type natriuretic peptide in a variety of cardiovascular diseases. The participants were Dr. Marc A. Silver, Advocate Christ Medical Center, Oak Lawn, IL; Dr. Clive Rosendorff, Mount Sinai School of Medicine, New York, NY and VA Medical Center, Bronx, NY; Dr. Robert Berkowitz, Hackensack University Medical Center, Hackensack, NJ; and Dr. W. Franklin Peacock IV, The Cleveland Clinic Department of Emergency Medicine, Cleveland, OH. Dr. Silver moderated the discussion. The panel gathered to review some of the questions that emerged from the symposium and the questions raised by the attendees. These are of interest and importance to all interested in heart failure and B-type natriuretic peptide.
Heart Failure↗
Acute and chronic oral magnesium supplementation: effects on endothelial function, exercise capacity, and quality of life in patients with symptomatic heart failure.
Endothelial dysfunction is an important pathophysiologic mechanism in the progression of heart failure. The objective of the present study was to determine the effects of acute and chronic oral magnesium supplementation on endothelial function in patients with symptomatic heart failure. Twenty-two symptomatic chronic heart failure patients were randomized to receive 800 mg oral magnesium oxide daily or placebo for 3 months. Data collected included large and small arterial elasticity/compliance, hemodynamic parameters, exercise capacity, and quality-of-life score at baseline, 1 week, and 3 months. Patients who received magnesium had improved small arterial compliance at 3 months from baseline compared with placebo. This study suggests that chronic supplementation with oral magnesium is well tolerated and could improve endothelial function in symptomatic heart failure patients.
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Optimizing treatment and outcomes in acute heart failure: beyond initial triage.
Heart failure contributes substantially to health care costs in the United States due to its prevalence and frequent necessity for repeat hospitalizations to manage episodes of acute decompensation. Heart failure overwhelmingly impacts Medicare costs, as the highest proportion of heart failure patients are older than 65 years of age. Efforts to reduce morbidity, mortality, and health care resource utilization have been achieved successfully through emergency department-based heart failure observation units. For select patients, the observation unit can provide care with effective oral agents, including angiotensin-converting enzyme inhibitors, beta-adrenergic receptor blockers, and diuretics, as well as administration of other vasoactive agents, followed by a discharge plan of effective heart failure education and rigorous follow-up management. As advanced pharmacologic and diagnostic therapies continue to emerge, the observation unit staff can play an integral role in the critical education and self-management tools that are needed by the patient to ultimately improve outcomes and quality of life.
Acute Disease↗
Enhanced external counterpulsation improves exercise duration and peak oxygen consumption in older patients with heart failure: a subgroup analysis of the PEECH trial.
The Prospective Evaluation of Enhanced External Counterpulsation in Congestive Heart Failure (PEECH) trial demonstrated that enhanced external counterpulsation (EECP) therapy increased exercise duration and improved functional status and quality of life without affecting peak oxygen consumption. The authors present data from a prespecified subgroup of elderly patients (65 years or older) enrolled in the PEECH trial. The 2 co-primary end points were the percentage of subjects with a >60-second increase in exercise duration and the percentage of subjects with a >1.25-mL/kg/min increase in peak volume of oxygen consumption. At 6-month follow-up, the exercise responder rate was significantly higher in EECP patients compared with controls (P=.008). Further, in contrast to the overall PEECH study, the EECP group demonstrated a significantly higher responder rate for peak oxygen consumption (P=.017). The authors conclude that an older subgroup of PEECH subjects confirms the beneficial effect of EECP in patients with chronic, stable, mild-to-moderate heart failure.
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