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Mihai Gheorghiade

Publications and source records attributed to Mihai Gheorghiade.

At least 19 recordsLinked to original sources
PubMed2005

Demographics, clinical characteristics, and outcomes of patients hospitalized for decompensated heart failure: observations from the IMPACT-HF registry.

BACKGROUND: Hospitalizations for decompensated heart failure are frequent. The Initiation Management Pre-discharge Assessment of Carvedilol Heart Failure (IMPACT-HF) registry collected observational data in patients hospitalized for worsening heart failure to characterize an unselected group of patients and to confirm the generalizability of the IMPACT-HF main trial population. METHODS AND RESULTS: The IMPACT-HF registry was conducted concurrently with the IMPACT-HF study, a randomized trial of in-hospital initiation of carvedilol compared with the standard practice of postdischarge beta-blocker initiation. Patients were eligible for registry enrollment if they were hospitalized for heart failure regardless of ejection fraction. There were no exclusions to participation. Patients were followed for 60 days. The IMPACT-HF Registry enrolled 567 patients. The mean age was 71 years, 52% of the patients were men and 82% were Caucasian. At discharge, 71% received an angiotensin-converting enzyme inhibitor or angiotensin receptor blocker, 41% received digoxin, and 62% received beta-blockers. The 60-day rate of rehospitalization or death was 31%. CONCLUSION: The IMPACT-HF registry enrolled elderly patients admitted for worsening heart failure primarily resulting from progressive volume overload. The 60-day rate of death or rehospitalization was high despite the use of evidence-based therapies. New treatments for this population are needed to decrease the morbidity and mortality associated with decompensated heart failure.

Adrenergic beta-Antagonists↗
PubMed2004

Importance of in-hospital initiation of evidence-based medical therapies for heart failure-a review.

Patients who have had heart failure (HF) face very high risks of hospitalization and mortality. Despite the compelling scientific evidence that angiotensin-converting enzyme inhibitors, aldosterone antagonists, and beta blockers decrease rates of hospitalization and mortality in patients who have had HF, these life-prolonging therapies continue to be underused. Many studies in a variety of clinical settings have documented that important numbers of patients who have had HF are not receiving treatment with these evidence-based therapies, which are recommended by national guidelines, when guided by conventional care. This HF treatment gap results from a variety of complex issues, including lack of systems and disease management programs. This gap in beta-blocker therapy may be due in part to persisting perceptions, despite recent evidence to the contrary, that it should be delayed until patients who developed HF have been stable for 2 to 4 weeks after hospital discharge and that its initiation results in a substantial risk of worsening HF. Conversely, recent clinical trial evidence has substantiated that beta blockers can be safely initiated for patients with HF in the hospital and that there are early benefits, including decreased risks of mortality and hospitalization for worsening HF. It has become increasingly evident that in-hospital initiation of evidence-based cardiovascular therapies and patient education have a positive effect on long-term patient compliance and clinical outcomes. Adopting in-hospital initiation of these therapies as the standard of care (in the absence of contraindications or intolerance) in patients who have HF and stabilized systolic dysfunction could substantially improve treatment rates, decrease the risk of future hospitalizations, and prolong life in the large number of patients who are hospitalized each year for HF.

Adrenergic beta-Antagonists↗
PubMed2004

Usefulness of an elevated troponin-I in predicting clinical events in patients admitted with acute heart failure and acute coronary syndrome (from the RITZ-4 trial).

The relation of cardiac troponin-I (cTnI) to clinical outcomes was examined in patients with decompensated heart failure and concomitant acute coronary syndrome enrolled into the Randomized Intravenous TeZosentan 4 (RITZ-4) study. RITZ-4 was a multicenter, randomized, double-blind, placebo-controlled trial of the endothelin receptor antagonist tezosentan in patients admitted with acute heart failure and concomitant acute coronary syndrome. One hundred ninety-two patients were enrolled in this study. Patients with baseline cTnI values were included in this analysis, and the relation between cTnI and the composite clinical primary end point of RITZ-4 was evaluated.

Acute Disease↗
PubMed2004

Role of carvedilol in atrial fibrillation: insights from clinical trials.

Atrial fibrillation affects approximately 2 million people in the United States and is a common comorbidity among patients with heart failure. Clinical studies indicate that the benefits of the beta-blocker carvedilol in patients with heart failure extend to patients with heart failure complicated by atrial fibrillation. The results of the Carvedilol in Atrial Fibrillation Evaluation (CAFE) trial provide support that carvedilol has incremental benefit when added to digoxin for the management of atrial fibrillation in patients with heart failure. Additional recent studies suggest that carvedilol may be useful in managing postsurgical atrial fibrillation and also may prevent recurrence of atrial fibrillation among patients who undergo cardioversion.

Adrenergic beta-Antagonists↗
PubMed2004

Predischarge initiation of carvedilol in patients hospitalized for decompensated heart failure: results of the Initiation Management Predischarge: Process for Assessment of Carvedilol Therapy in Heart Failure (IMPACT-HF) trial.

OBJECTIVES: The Initiation Management Predischarge: Process for Assessment of Carvedilol Therapy in Heart Failure (IMPACT-HF) trial was an investigator-initiated study to evaluate if predischarge carvedilol initiation in stabilized patients hospitalized for heart failure (HF) increased the number of patients treated with beta-blockade at 60 days after randomization without increasing side effects or length of hospital stay. BACKGROUND: Beta-blockers are underused in HF. Predischarge initiation may improve the use of evidence-based beta-blockade. METHODS: The IMPACT-HF was a prospective, randomized open-label trial conducted in 363 patients hospitalized for HF. Patients were randomized to carvedilol initiation pre-hospital discharge or to postdischarge initiation (>2 weeks) of beta-blockade at the physicians' discretion. The primary end point of the study was the number of patients treated with beta-blockade at 60 days after randomization. Secondary end points included the number of patients discontinuing beta-blockade, median dose achieved, and a composite of death, rehospitalization, unscheduled visit for HF, or > or =50% increase in oral diuretic, new oral diuretic, or any intravenous therapy with diuretics, inotropes, or other vasoactive agents. RESULTS: At 60 days 165 patients (91.2%) randomized to predischarge carvedilol initiation were treated with a beta-blocker, compared with 130 patients (73.4%) randomized to initiation postdischarge (p < 0.0001). Predischarge initiation was not associated with an increased risk of serious adverse events. The median length of stay was five days in both groups. CONCLUSIONS: Predischarge initiation of carvedilol in stabilized patients hospitalized for HF improved the use of beta-blockade at 60 days without increasing side effects or length of stay. Predischarge initiation may be one approach to improve beta-blocker use in this population.

Adrenergic beta-Antagonists↗
PubMed2004

Effects of tolvaptan, a vasopressin antagonist, in patients hospitalized with worsening heart failure: a randomized controlled trial.

CONTEXT: Nearly 1 million hospitalizations for chronic heart failure occur yearly in the United States, with most related to worsening systemic congestion. Diuretic use, the mainstay therapy for congestion, is associated with electrolyte abnormalities and worsening renal function. In contrast to diuretics, the vasopressin antagonist tolvaptan may increase net volume loss in heart failure without adversely affecting electrolytes and renal function. OBJECTIVE: To evaluate the short- and intermediate-term effects of tolvaptan in patients hospitalized with heart failure. DESIGN, SETTING, AND PARTICIPANTS: Randomized, double-blind, placebo-controlled, parallel-group, dose-ranging, phase 2 trial conducted at 45 centers in the United States and Argentina and enrolling 319 patients with left ventricular ejection fraction of less than 40% and hospitalized for heart failure with persistent signs and symptoms of systemic congestion despite standard therapy. INTERVENTION: After admission, patients were randomized to receive 30, 60, or 90 mg/d of oral tolvaptan or placebo in addition to standard therapy, including diuretics. The study drug was continued for up to 60 days. MAIN OUTCOME MEASURES: In-hospital outcome was change in body weight at 24 hours after randomization; outpatient outcome was worsening heart failure (defined as death, hospitalization, or unscheduled visits for heart failure) at 60 days after randomization. RESULTS: Median (interquartile range) body weight at 24 hours after randomization decreased by -1.80 (-3.85 to -0.50), -2.10 (-3.10 to -0.85), -2.05 (-2.80 to -0.60), and -0.60 (-1.60 to 0.00) kg in the groups receiving tolvaptan 30, 60, and 90 mg/d, and placebo, respectively (P< or =.008 for all tolvaptan groups vs placebo). The decrease in body weight with tolvaptan was not associated with changes in heart rate or blood pressure, nor did it result in hypokalemia or worsening renal function. There were no differences in worsening heart failure at 60 days between the tolvaptan and placebo groups (P =.88 for trend). In post hoc analysis, 60-day mortality was lower in tolvaptan-treated patients with renal dysfunction or severe systemic congestion. CONCLUSION: Tolvaptan administered in addition to standard therapy may hold promise for management of systemic congestion in patients hospitalized for heart failure.

Ambulatory Care↗
PubMed2004

Effects of amino acid supplementation on left ventricular remodeling in patients with chronic heart failure with decreased systolic function and diabetes mellitus: rationale and design of a magnetic resonance imaging study.

A considerable number of patients with reduced systolic function caused by primary or ischemic cardiomyopathy have viable and noncontractile myocardium. This may be related to numerous and perhaps overlapping factors, such as chronic ischemia (stunning/hibernation), neurohormonal abnormalities, oxidative stress, metabolic imbalances, and/or nutritional depletion. Changes in myocardial substrate utilization have adverse effects on the metabolism of the viable but noncontractile myocardium. Shifting the energy substrate preference away from fatty acids and replenishing the tricarboxylic acid cycle components via amino acids rather than via fatty acids would increase adenosine triphosphate production, with positive effects on cellular metabolism. A proposed study design is described and will be piloted through the Effects of Diatrofen on Myocardial Function in Patients with Chronic Heart Failure trial (D-CHF), an evaluation of an oral amino acid supplementation treatment in outpatients with heart failure.

Administration, Oral↗
PubMed2004

Relation between contractile reserve and improvement in left ventricular function with beta-blocker therapy in patients with heart failure secondary to ischemic or idiopathic dilated cardiomyopathy.

Beta blockers improve left ventricular (LV) ejection fraction but patient responses are heterogenous. We investigated the role of contractile reserve (CR) in predicting beta-blocker response in ischemic and nonischemic cardiomyopathy. Resting and low-dose dobutamine echocardiograms were recorded in 32 patients with heart failure (LV ejection fraction <or=35%), 18 with ischemic cardiomyopathy (IC), and 14 with idiopathic dilated cardiomyopathy (IDC). A segment was defined as CR positive (CR+) or negative (CR-) based on response to dobutamine. Patients were then classified as CR+ or CR- based on number of improved segments (IC group) or ejection fraction improvement (IDC group) in response to dobutamine. During follow-up (2, 6, and 14 months after beta-blocker initiation), response was measured by the percent of segments showing improved contractility from baseline, ejection fraction, and wall motion score index. In the IC group, the percent of improved segments was greater at 2 and 6 months in CR+ versus CR- (70% vs 15% and 39% vs 17%, p <0.05), whereas it was greater at all periods in the patients with IDC (36% vs 9% at 2 months, 50% vs 19% at 6 months, and 63% vs 42% at 14 months, p <0.05). Findings for ejection fraction and wall motion score index were similar. Therefore, time course and magnitude of improvement in LV function in patients with heart failure receiving beta blockers are related to CR status. CR predicts a greater early response in IC, whereas it predicts a greater response at all time periods in IDC. However, even patients without CR showed improvement in LV function at 14 months.

Adrenergic beta-Antagonists↗
PubMed2004

The diabetes epidemic: a national and global crisis.

Diabetes mellitus is a serious problem that will soon reach epidemic proportions in the United States and throughout the world. The incidence of this condition will skyrocket in the next quarter century as demographic changes increase the size of highly susceptible populations (e.g., the elderly and Hispanic communities) and sociocultural developments create a more sedentary populace as well as expose people in developing nations to new risk factors for this disease. Along with substantial direct morbidity and mortality, diabetes is independently associated with the incidence and severity of a variety of cardiovascular illnesses. Individuals with diabetes are substantially more likely than their nondiabetic counterparts to suffer stroke, myocardial infarction, or heart failure, with a worse prognosis following any of these conditions. Many factors may be relevant to this association, but recent studies have elucidated a major role for the metabolic syndrome, which has been shown to be predictive of both diabetes and cardiovascular disease. Consequently, early intervention to control blood glucose levels and other risk factors may mitigate the severity of these conditions, possibly even before the disease begins.

Cardiovascular Diseases↗
PubMed2004

Management of the patient with diabetes mellitus and myocardial infarction: clinical trials update.

The increasing prevalence of diabetes mellitus and its association with cardiovascular disease have become serious public health issues. Although diabetes and coronary artery disease (CAD) may have different clinical manifestations, their atherosclerotic burden and prognosis are quite similar. However, patients with diabetes who have underlying CAD have a different, more complex pathophysiology and a worse prognosis. Optimal management of these patients requires a comprehensive multifactorial approach to prevent microvascular and macrovascular events. In the setting of an acute myocardial infarction (MI), immediate management should focus on limiting infarct size. This can be achieved by using fibrinolytic agents, primary percutaneous intervention (in ST-segment elevation MI), or glycoprotein IIb/IIIa inhibitors followed by coronary angiography within 24 to 48 hours and, when appropriate, by coronary intervention (in non-ST-segment elevation MI). Drug-eluting stents may have an important role in patients with diabetes, who have a higher rate of postintervention coronary restenosis than do nondiabetic individuals. In addition, all patients with an acute MI (ST- and non-ST-segment elevation) should be given aspirin, nitrates, beta-blockers, and angiotensin-converting enzyme (ACE) inhibitors. The long-term pharmacologic management after MI is similar in all patients, regardless of the initial presentation. Antiplatelet agents (aspirin and/or clopidogrel), ACE inhibitors, beta-blockers, lipid-lowering agents, and glycemic control have all been shown to be effective in decreasing long-term mortality. Despite advances in the management of MI, the mortality rates of patients with diabetes remain 1.5- to 2-fold greater than those of persons without diabetes. Maximizing the use of lifesaving therapies proved effective in large randomized clinical trials and tight metabolic control can further decrease mortality rates. However, many of these lifesaving therapies are underused in patients with diabetes because of the misconception that potential adverse effects may outweigh their benefits. New programs aimed at improving postinfarction quality of care in patients with diabetes, based on guidelines and expert recommendations, have shown promise. However, more effort must be devoted to the improvement of outcomes related to these public health problems.

Clinical Trials as Topic↗
PubMed2004

New insights into diastolic heart failure: role of diabetes mellitus.

Heart failure affects nearly 5 million people in the United States and is a major contributor to mortality, hospitalization, and medical costs. Approximately 40% of patients with heart failure have preserved left ventricular systolic function, thus exhibiting diastolic heart failure. More common in women and the elderly, this condition is associated with hypertension, coronary artery disease, and/or atrial fibrillation. With the exception of the Digitalis Investigation Group (DIG) and the Candesartin in Heart Failure: Assessment of Reduction in Mortality and Morbidity (CHARM)-Preserved trials, no completed large randomized clinical trial has addressed the management of such patients. Symptomatic treatment involves administration of diuretics and nitrates, but long-term management with angiotensin-converting enzyme inhibitors, angiotensin-receptor blockers, aldosterone antagonists, beta-blockers, and calcium channel blockers targets the underlying disorders. Recent studies found that diabetes mellitus produces functional, biochemical, and morphologic myocardial abnormalities independent of coronary atherosclerosis and hypertension. These abnormalities may result in impaired left ventricular diastolic function, contributing importantly to heart failure with normal systolic function. Although tight glycemic control decreases the risk of heart failure in patients with diabetes, the effects of different diabetic treatment regimens on heart failure with normal systolic function are unknown and remain subject to future investigation.

Aging↗
PubMed2004

Closing statement.

Explore the source record for details and available documents.

Cardiovascular Diseases↗
PubMed2004

Mitral regurgitation in chronic heart failure: more questions than answers?

The presence, implications, and approach to mitral valvular disease in the setting of a cardiomyopathy has recently become a focal issue for discussion. Although recent evidence suggests that mitral regurgitation confers a poor prognosis in heart failure, the true prevalence of mitral regurgitation as well as its pathogenic contribution to prognosis in heart failure remains uncertain. Whereas angiotensin-converting enzyme inhibitors have not been demonstrated to favorably alter mitral regurgitation, treatment with b-blockers or cardiac resynchronization therapy has been shown to induce regression of ventricular dilation, with consequent decrease in mitral regurgitation. Surgical valve reconstruction by undersized ring annuloplasty appears promising, but optimal results require skilled surgical expertise. Even in highly experienced hands, intermediate outcomes appear to be inferior to those of cardiac transplantation. Percutaneous mitral valve repair remains an investigational procedure that warrants further clinical research.

Heart Failure↗
PubMed2004

Organized Program to Initiate Lifesaving Treatment in Hospitalized Patients with Heart Failure (OPTIMIZE-HF): rationale and design.

Heart failure (HF) affects >5 million patients in the United States, and its prevalence is increasing every year. Despite the compelling scientific evidence that angiotensin-converting enzyme inhibitors and beta-blockers reduce hospitalizations and mortality rates in patients with HF, these lifesaving therapies continue to be underused. Several studies in a variety of clinical settings have documented that a significant proportion of eligible patients with HF are not receiving treatment with these guideline-recommended, evidence-based therapies. In patients hospitalized with HF, who are at particularly high risk for re-hospitalization and death, the initiation of beta-blockers is often delayed because of concern that early initiation of these agents may exacerbate HF. Recent studies suggest that beta-blockers can be safely and effectively initiated in patients with HF before hospital discharge and that clinical outcomes are improved. The Initiation Management Predischarge Process for Assessment of Carvedilol Therapy for Heart Failure (IMPACT-HF) trial demonstrated that pre-discharge initiation of carvedilol was associated with a higher rate of beta-blocker use after hospital discharge, with no increase in hospital length of stay. In addition, there was no increase in the risk of worsening of HF. Studies of hospital-based management systems that rely on early (pre-discharge) initiation of evidence-based therapies for patients with cardiovascular disease have also found increases in post-discharge use of therapy and a reduction in the rates of mortality and hospitalization. On the basis of these pivotal studies, the Organized Program to Initiate Lifesaving Treatment in Hospitalized Patients with Heart Failure (OPTIMIZE-HF) program is designed to improve medical care and education of hospitalized patients with HF and accelerate the initiation of evidence-based HF guideline recommended therapies by administering them before hospital discharge. A registry component, planned as the most comprehensive database of the hospitalized HF population focusing on admission to discharge and 60- to 90-day follow-up, is designed to evaluate the demographic, pathophysiologic, clinical, treatment, and outcome characteristics of patients hospitalized with HF. The ultimate aim of this program is to improve the standard of HF care in the hospital and outpatient settings and increase the use of evidence-based therapeutic strategies to save lives.

Adrenergic beta-Antagonists↗
PubMed2004

The impact of arrhythmias in acute heart failure.

BACKGROUND: Arrhythmias are common in chronic heart failure and affect outcomes. The incidence and significance of new arrhythmias in acute heart failure, however, are largely unknown. METHODS AND RESULTS: The Outcomes of a Prospective Trial of Intravenous Milrinone for Exacerbations study randomized 949 patients with decompensated heart failure to receive intravenous milrinone or placebo. In the study, patients were divided into 2 groups based on the occurrence of a new arrhythmic event during their index hospitalization and analyzed for outcome. There were 59 new arrhythmic events occurring in 6% of the population. Of these, 49% were atrial fibrillation/flutter. The primary endpoint of days hospitalized for cardiovascular causes within 60 days after randomization was 30.9+/-22.7 for those in the arrhythmia group and 11.3+/-12.7 days for those with no arrhythmias (P=.0001). Mortality during index hospitalization was 26% in the arrhythmia group and 1.8% in the no arrhythmia group (P=.001). Death or hospitalization at 60 days was also worse in the arrhythmia group (35 versus 8.2%, P=.0001; 57 versus 34%, P=.001, respectively). Cox proportional hazard analysis identified new arrhythmias as an independent risk factor for the primary endpoint and death at 60 days. CONCLUSION: New arrhythmia during an exacerbation of heart failure identifies a high-risk group with higher intrahospital and 60-day morbidity and mortality.

Acute Disease↗
PubMed2004

Risk stratification after hospitalization for decompensated heart failure.

BACKGROUND: Decompensated heart failure (HF) is among the most common indications for hospitalization in the United States, but little is known about features on admission that predict adverse events. We used data from the Outcomes of a Prospective Trial of Intravenous Milrinone for Exacerbations of Chronic Heart Failure (OPTIME-CHF) study to develop a model that would predict outcomes in patients with decompensated HF. METHODS AND RESULTS: OPTIME-CHF randomized 949 patients hospitalized with decompensated HF for 48 to 72 hours of infusion of either milrinone or placebo. We used multivariable modeling to evaluate variables on admission that would be predictive of 60-day mortality or the composite of death or rehospitalization at 60 days. Variables at presentation that predicted death at 60 days were increased age, lower systolic blood pressure, New York Heart Association class IV symptoms, elevated blood urea nitrogen (BUN), and decreased sodium. Predictors of the composite of death or rehospitalization within 60 days were the number of HF hospitalizations in the preceding 12 months, elevated BUN, lower systolic blood pressure, decreased hemoglobin, and a history of percutaneous coronary intervention (PCI). The discriminatory power of the model was substantial for the mortality model (c-index .77) but less for the composite endpoint (c-index .69). CONCLUSIONS: Risk stratification of patients with decompensated HF may be accomplished using easily assessed clinical variables. Further research into the validity of this model in independent samples will potentially aid in the development of risk stratification strategies.

Aged↗