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PubMed1990

Regulation of circulation in congestive heart failure.

Regulation of extremity (limb) circulation was studied in 21 patients suffering from congestive heart failure. In 11 cases the peripheral circulation was intact, while 10 patients also suffered from peripheral obliterative arterial disease. Data of 75 patients with normal cardiac condition served as control: 35 subjects with intact peripheral circulation and 40 patients suffering from peripheral obliterative arterial disease. Limb blood flow was measured by using venous isotope dilution technique. Cardiac output was determined by the dye dilution method. In chronic heart failure the limb circulation characteristically deviated from the normal; the limb blood flow and the limb oxygen consumption slightly decreased, while the limb vascular resistance markedly increased. The diminution of the limb blood flow and the increase in the limb vascular resistance due to obliterative arterial disease were more pronounced in patients suffering from congestive heart failure. The pathological increase in the peripheral vascular resistance due to chronic heart failure proved mostly reversible; on the administration of vasodilator drugs the elevated limb vascular resistance markedly decreased and the limb blood flow significantly increased.

Adult↗

PubMed1979

Cardiac output and contractility indices: establishing a standard in response to low-to-moderate level exercise in healthy men.

Measurement by impedance cardiography (ZCG) of cardiac output and contractility indices during exercise is a recent addition to exercise testing of the cardiac patient. To provide a needed standard of normal responses to exercise at integrals of resting oxygen consumption (METS), 10 healthy men were tested. Basal oxygen consumption (1MET) under standardized conditions was measured by mass spectrometry. Over several days the subjects were exercised on a treadmill at 2METS through 6METS with monitoring of heart rate, electrocardiogram, oxygen consumption per minute (VO2) and ZCG. The exercise routine was then repeated to look for test-retest effect. Values closely approximating presently accepted basal oxygen consumptions were achieved under these standardized but practical conditions. Cardiac output during sitting, fully supported rest was slightly higher than that at 2METS on treadmill owing to higher stroke volume. From 2METS through 6METS the curvilinear mean heart rate and stroke volume were mirror images, producing a linear increase in mean cardiac output which at 6METS was 145% of basal and 160% of the 2MET value, while the contractility index increased to 217% of basal. Comparison of the 2 trials revealed no significant test-retest effect.

Adult↗

PubMed1978

Altered hemodynamic responses to acute hypoxemia in spontaneously hypertensive rats.

Conscious spontaneously hypertensive rats (SHR), 5--7 wk old, were studied hemodynamically by the direct Fick procedure to determine whether high total peripheral resistance (TPR) coexisted with increased oxygen consumption (QO2) at an early stage of hypertension development. Since under resting conditions cardiac output in SHR was not significantly different from normotensive controls, the elevated arterial pressure and QO2 were associated with increased TPR. Arterial hypoxemia was induced to reduce oxygen availability and to assess whether increased TPR in SHR could be reversed by this procedure. During hypoxemia, normotensive controls (WKY) responded with increased cardiac output and decreased arterial pressure and TPR. In contrast, arterial pressure and cardiac output fell in SHR; and the increased TPR persisted. QO2 fell in hypoxemic SHR demonstrating that the relationship between total body oxygen consumption and cardiac output was abnormal in young SHR, and that increased TPR in SHR was not dependent on resting levels of QO2 or oxygen availability. Although QO2 was elevated in SHR compared to age-matched WKY, this condition was not essential for maintained elevated vascular resistance.

Aging↗

PubMed1998

Cardiac retransplantation for graft vasculopathy in children: should we continue to do it?

BACKGROUND: Cardiac transplantation (CTx) has been established as an effective therapy for a variety of inoperable cardiac conditions in infants and children. However, graft vasculopathy (GV) has emerged as the main limiting factor to long-term survival of CTx recipients. The only treatment of severe GV is cardiac retransplantation (re-Tx). Controversy exists regarding the use of scarce donor organs for cardiac re-Tx. OBJECTIVE: To compare the outcome of cardiac re-Tx for GV with that of primary CTx in children. DESIGN: A 12-year retrospective cohort review. SETTING: A university-affiliated children's hospital. PATIENTS: All infants and children who underwent CTx (group 1, n = 322) had complete follow-up of 1389.7 patient-years. Graft vasculopathy was confirmed in 32 recipients (1.1-8.2 years after undergoing CTx). Thirteen patients died suddenly, 3 died waiting for cardiac re-Tx (1-17 days after relisting), 4 are pending cardiac re-Tx, and 12 (group 2) underwent cardiac re-Tx. INTERVENTION: Cardiac re-Tx at a mean (+/- SD) interval from the first CTx of 6.3 +/- 1.8 years (range, 2.2-9.4 years). Two patients required additional aortic arch aneurysm repair with cardiac re-Tx. RESULTS: When group 1 was compared with group 2, there was no significant difference in operative mortality (9.0% vs 8.3%; P = .9), rejection rate (0.98 vs 0.86; P = .1), and hospital stay (23.0 +/- 18.8 days vs 20.5 +/- 11.6 days; P = .65). Actuarial survival for groups 1 and 2 at 1 and 4 years was 84.3% vs 83.3% (P = .59) and 74.4% vs 83.3% (P = .85), respectively. CONCLUSIONS: The surgical outcome and intermediate survival of cardiac re-Tx for GV and primary CTx are similar. Children with severe cardiac GV are at risk of sudden death and can benefit from early cardiac re-Tx.

Child, Preschool↗

PubMed2000

Management of sexual dysfunction in patients with cardiovascular disease: recommendations of The Princeton Consensus Panel.

Sexual dysfunction is highly prevalent in both sexes and adversely affects patients' quality of life and well being. Given the frequent association between sexual dysfunction and cardiovascular disease, in addition to the potential cardiac risk of sexual activity itself, a consensus panel was convened to develop recommendations for clinical management of sexual dysfunction in patients with cardiovascular disease. Based upon a review of the research and presentations by invited experts, a classification system was developed for stratification of patients into high, low, and intermediate categories of cardiac risk. The large majority of patients are in the low-risk category, which includes patients with (1) controlled hypertension; (2) mild, stable angina; (3) successful coronary revascularization; (4) a history of uncomplicated myocardial infarction (MI); (5) mild valvular disease; and (6) no symptoms and <3 cardiovascular risk factors. These patients can be safely encouraged to initiate or resume sexual activity or to receive treatment for sexual dysfunction. An important exception is the use of sildenafil in patients taking nitrates in any form. Patients in the intermediate-risk category include those with (1) moderate angina; (2) a recent MI (<6 weeks); (3) left ventricular dysfunction and/or class II congestive heart failure; (4) nonsustained low-risk arrhythmias; and (5) >/=3 risk factors for coronary artery disease. These patients should receive further cardiologic evaluation before restratification into the low- or high-risk category. Finally, patients in the high-risk category include those with (1) unstable or refractory angina; (2) uncontrolled hypertension; (3) congestive heart failure (class III or IV); (4) very recent MI (<2 weeks); (5) high-risk arrhythmias; (6) obstructive cardiomyopathies; and (7) moderate-to-severe valvular disease. These patients should be stabilized by specific treatment for their cardiac condition before resuming sexual activity or being treated for sexual dysfunction. A simple algorithm is provided for guiding physicians in the management of sexual dysfunction in patients with varying degrees of cardiac risk.

Humans↗

PubMed2000

Management of sexual dysfunction in patients with cardiovascular disease: recommendations of the Princeton Consensus Panel.

Adult↗

PubMed2001

Synaptic and neurotransmitter activation of cardiac vagal neurons in the nucleus ambiguus.

Cardiac vagal neurons play a critical role in the control of heart rate and cardiac function. These neurons, which are primarily located in the nucleus ambiguus (NA) and the dorsal motor nucleus of the vagus (DMNX), dominate the neural control of heart rate under normal conditions. Cardiac vagal activity is diminished and unresponsive in many disease states, while restoration of parasympathetic activity to the heart lessens ischemia and arrhythmias and decreases the risk of sudden death. Recent work has demonstrated that cardiac vagal neurons are intrinsically silent and therefore rely on synaptic input to control their firing. To date, three major synaptic inputs to cardiac vagal neurons have been identified. Stimulation of the nucleus tractus solitarius evokes a glutamatergic pathway that activates both NMDA and non-NMDA glutamatergic postsynaptic currents in cardiac vagal neurons. Acetylcholine excites cardiac vagal neurons via three mechanisms, activating a direct ligand-gated postsynaptic nicotinic receptor, enhancing postsynaptic non-NMDA currents, and presynaptically by facilitating transmitter release. This enhancement by nicotine is dependent upon activation of pre- and postsynaptic P-type voltage-gated calcium channels. Additionally, there is a GABAergic innervation of cardiac vagal neurons. The transsynaptic pseudorabies virus that expresses GFP (PRV-GFP) has been used to identify, for subsequent electrophysiologic study, neurons that project to cardiac vagal neurons. Bartha PRV-GFP-labeled neurons retain their normal electrophysiological properties, and the labeled baroreflex pathways that control heart rate are unaltered by the virus.

Animals↗

PubMed1991

Depression and chronic fatigue in the patient with heart disease.

Depression and chronic fatigue are frequently associated with heart disease. They may precede the onset of myocardial infarction, singly or together, and increase the morbidity and mortality of patients with a history of MI. Virtually all such patients have a transient depression, usually accompanied by anxiety, with onset soon after hospitalization. Although this depression is transient and usually abates spontaneously, it frequently warrants therapeutic intervention. Psychosocial and personality factors play a significant role in the recovery of a patient with a cardiac condition. The clinician must be alert for the effects of changing roles within the family and behaviors that may lead to chronic invalidism. Anxiety disorders, often combined with depression, may mimic cardiac disease and may result from it, leading to chronic fatigue and weakness. Proper diagnosis usually leads to considerable improvement. Cardiac drugs, in addition to many others, may produce depression and fatigue that may be misdiagnosed. Often, discontinuing or changing a medication will lead to marked diminution of such symptoms. Observational and listening skills are key ingredients of the "art" of medicine; they can lead to interventions that are not only therapeutic, but which improve the "quality" of life.

Depression↗

PubMed2006

Electrocardiographic markers of sudden death.

The 12-lead ECG has limited utility to predict the risk for sudden cardiac death in common cardiac diseases such as coronary artery disease and idiopathic dilated cardiomyopathy. However, it is quite useful in diagnosing less common cardiac conditions that are associated with an increased risk for sudden death.

Biomarkers↗

PubMed1978

[Usefulness of x-ray parameters in the functional evaluation of patients with nonvalvular cardiopathies].

In 49 patients suffering of heart diseases we have studied the changes of radiologic cardiac measurements and systolic time intervals (STI) in the four functional classes of the New York Heart Association (NYHA) classification, investigating also the existence of any relationship between these different parameters. Only the patients in functional classes 3rd and 4th showed significant changes in STI and radiologic measurements as compared to the control group. Moreover, a significant negative correlation has been observed between relative heart volume and left ventricular ejection time (LVET) (r = 0.69, P less than 0.001) and LVETc (r = 0.82, P less than 0.001) and a positive correlation between relative heart volume and pre-ejection period (PEP) (r = 0.59, P less than 0.01) and PEP/LVET ratio (r = 0.75, P less than 0.001). These results seem to demonstrate that relative heart volumetry is a fairly accurate index of the cardiac conditions in non valvular heart diseases.

Adult↗

PubMed2004

The fifty percent male excess of infant respiratory mortality.

AIM: To test whether infant mortality from clearly respiratory causes has a consistent male excess that is different from the male excess in most cardiac conditions. METHODS: Analysis of male excess in infant mortality data from the United States and from north European countries. Data are analyzed for the period 1979-2002 in autopsied and unautopsied cohorts. RESULTS: Several modes of respiratory death in infancy are characterized by an approximate 50% male excess. This common excess is demonstrated in vital statistics for infant respiratory distress syndrome, sudden infant death syndrome, inhalation of food and other objects causing obstruction of respiratory tract or suffocation, congenital pneumonia, viral pneumonia, bronchiolitis and bronchitis, and accidental drowning. Results are presented for these and other respiratory causes of mortality in all United States infant deaths from 1979-1998 and for sudden infant death syndrome from the United Kingdom and Scandinavia. In sudden infant death syndrome, the common male excess appears to exist only for the autopsied post-neonatal cases. Comparisons are made to the male excess mortality from congenital cardiac anomalies showing a similarly large male excess for those conditions resulting in severe hypoxic and ischemic hypoxia. CONCLUSION: Because these respiratory disease conditions are quite different, it is proposed that their common approximately 50% male excess implies a common terminal hypoxic condition and mechanism of death reached via the different pathways. We hypothesize that an unknown X-linkage may be responsible for this consistent male excess in infant mortality.

Europe↗

PubMedDate not supplied

Antibiotic prophylaxis in patients with infectious risk factors undergoing gastrointestinal endoscopic procedures.

UNLABELLED: Consecutive patients undergoing gastrointestinal endoscopic procedures were prospectively evaluated for the presence of risk factors for the development of infectious complications that indicated a need for prophylactic antibiotics. Criteria for the evaluation of risk factors were based on (a) former American Heart Association guidelines, (b) current American Heart Association guidelines, and (c) American Society for Gastrointestinal Endoscopy guidelines. Four hundred eighty-six patients underwent 507 procedures. Risk factors for the development of endocarditis or other infectious complications were found in 74 (15%) of all patients during the study period. Cardiac conditions in 51 patients were the most frequently encountered risk factor (69% of risk factors, 10% of all patients), with mitral valve prolapse in 25 patients accounting for 49% of patients with cardiac risk factors and 5% of all patients. Of the patients with mitral valve prolapse, 7 (28%, 1.4% of all study patients) had associated valvular regurgitation. None of the patients with mitral valve prolapse knew whether or not they had associated valvular regurgitation, and if they had had a previous echocardiogram, they were unaware of the results. Only 0.8% of patients had a prosthetic heart valve. The most common non-cardiac risk factor was the presence of a prosthetic joint (9 of 486, 1.8%). Of the 486 patients, 14 required antibiotic prophylaxis according to the above-mentioned guidelines. Six of the 14 patients were given either a non-recommended antibiotic or the wrong dose of a recommended antibiotic. CONCLUSIONS: (1) A decision regarding whether to administer antibiotic prophylaxis had to be made in 15% of patients undergoing endoscopy.(ABSTRACT TRUNCATED AT 250 WORDS)

Anti-Bacterial Agents↗

PubMed2004

Immunological changes in acute myocardial infarction.

OBJECTIVE: This study was undertaken to investigate troponin and lymphocyte subset changes in acute myocardial infarctions (AMI) and to correlate these changes with disease variables. METHODS: Forty-five patients with AMI admitted to the Coronary Care Unit, Jordan University Hospital and Queen Alia Heart Institute at King Hussein Medical Center, Amman, Jordan during the period November 1999 through to April 2000 were included in the study. Forty-five patients with non cardiac conditions were selected as a control group. Tests performed include; determination of the percentages of B-lymphocytes, T-lymphocytes and T-lymphocyte subsets by flow cytometry, measurements of serum cardiac troponin I (cTnI) by microparticle enzyme immunoassay and determination of minor blood groups by the gel test. RESULTS: A significant increase in the percentages of CD8+ and CD19+ cells combined with a significant decrease in the percentages of CD3+ and CD4+ cells as well as a decrease of CD4+/CD8+ ratio were documented in patients with AMI 24 hours after admission to the hospital. Except for CD19+ cells, all of cell types assayed for returned to their normal percentages before discharge of patients. Very low CD4+ cell percentages and CD4+/CD8+ ratio were found to be poor prognostic signs of AMI. Serum cTnI levels which were elevated in all patients correlate very well with the decreased CD4+ cell percentages, and the decreased CD4+/CD8+ cell ratio and they seem to correlate with the extensiveness of infarction. Troponin and lymphocyte subset changes, on the other hand, did not correlate with the number of vessels diseased or the risk factors for AMI. Finally, a statistically significant association was observed between the Le (a-b-) phenotype and AMI. CONCLUSION: Immunologic change seem to accompany or follow AMI and changes in T-lymphocyte subsets and cTnI can be regarded as prognostic markers in AMI but these changes are independent of risk factors and the number of vessels diseased.

Adult↗

PubMed1992

Cardiovascular causes of death at Tshepong Hospital in 1 year, 1989-1990. A necropsy study.

Cardiovascular disease is the third most common cause of death in Tshepong Hospital in the western Transvaal, and the most common cause of death in patients older than 35 years. A prospective study was undertaken which included limited necropsies in 90 of the 167 cardiovascular disease deaths over 1 year. A reliable mortality pattern for cardiovascular deaths is described. Additionally, attention is paid to co-existing conditions. Conditions relating to cardiovascular disease, such as hypertension, benign hypertensive nephrosclerosis, atherosclerosis and obesity, were also evaluated. Cerebrovascular conditions were found in 32% of cardiovascular deaths. Intracerebral haemorrhage was found in 50% and cerebral infarction in 29% of cases. Fifty-seven per cent of cardiovascular deaths were due to cardiac conditions, the most common being pulmonary hypertension (31%), dilated cardiomyopathy and chronic rheumatic valvular disease (17% each) and hypertensive heart disease (14%). Forty-nine per cent of subjects were hypertensive, while 40% exhibited benign nephrosclerosis and only 3% of the examined vessels had signs of severe atherosclerosis. Tuberculosis was present in 13% of cases. The clinical diagnosis was the same as the final necropsy diagnosis in 38% of cases. These results emphasise the importance of performing necropsies to obtain reliable mortality statistics.

Adolescent↗

PubMed1998

Energy metabolism and mechanical recovery after cardioplegia in moderately hypertrophied rats.

It is well established that severe hypertrophy induces metabolic and structural changes in the heart which result in enhanced susceptibility to ischemic damage during cardioplegic arrest while much less is known about the effect of cardioplegic arrest on moderately hypertrophied hearts. The aim of this study was to elucidate the differences in myocardial high energy phosphate metabolism and in functional recovery after cardioplegic arrest and ischemia in mildly hypertrophied hearts, before any metabolic alterations could be shown under baseline conditions. Cardiac hypertrophy was induced in rats by constriction of the abdominal aorta resulting in 20% increase in heart weight/body weight ratio (hypertrophy group) while sham operated animals served as control. In both groups, isolated hearts were perfused under normoxic conditions for 40 min followed by infusion of St.Thomas' Hospital No. 1 cardioplegia and 90 min ischemia at 25 degrees C with infusions of cardioplegia every 30 min. The changes in ATP, phosphocreatine (PCr) and inorganic phosphate (Pi) were followed by 31P nuclear magnetic resonance (NMR) spectroscopy. Systolic and diastolic function was assessed with an intraventricular balloon before and after ischemia. Baseline concentrations of PCr, ATP and Pi as well as coronary flow and cardiac function were not different between the two groups. However, after cardioplegic arrest PCr concentration increased to 61.8+/-4.9 micromol/g dry wt in the control group and to 46.3+/-2.8 micromol/g in hypertrophied hearts. Subsequently PCr, pH and ATP decreased gradually, concomitant with an accumulation of Pi in both groups. PCr was transiently restored during each infusion of cardioplegic solution while Pi decreased. PCr decreased faster after cardioplegic infusions in hypertrophied hearts. The most significant difference was observed during reperfusion: PCr recovered to its pre-ischemic levels within 2 min following restoration of coronary flow in the control group while similar recovery was observed after 4 min in the hypertrophied hearts. A greater deterioration of diastolic function was observed in hypertrophied hearts. Moderate hypertrophy, despite absence of metabolic changes under baseline conditions could lead to enhanced functional deterioration after cardioplegic arrest and ischemia. Impaired energy metabolism resulting in accelerated high energy phosphate depletion during ischemia and delayed recovery of energy equilibrium after cardioplegic arrest observed in hypertrophied hearts could be one of the underlying mechanisms.

Adenosine Triphosphate↗

PubMed1994

Thyrotoxicosis factitia in a post-aortocoronary bypass patient.

A 52-yr-old man presented with an evolving myocardial infarction and unstable angina. Previously, he had undergone aortocoronary bypass surgery for triple vessel disease and at that time was diagnosed as hypothyroid. He had been refractory to thyroxine treatment and now required 0.3 mg thyroxine daily. On admission, he was hypertensive, tachycardic and found to be thyrotoxic secondary to excess thyroid hormone ingestion. Treatment with iopanoic acid was started. Despite medical therapy he continued to have unstable angina. Coronary angiography confirmed further triple vessel disease with blockage to his previous grafts. He was taken to surgery for coronary revascularization. On arriving in the intensive care unit he developed a thyroid storm. His temperature increased from 36.5 to 39.5 degrees C requiring a cooling blanket and cold irrigation down a nasogastric tube. An esmolol infusion was started to control his persistent tachycardia but this depressed his myocardial contractility. He required amrinone and noradrenaline infusions as further inotropic support. For sedation and muscle relaxation, intravenous propofol infusion and doxacurium were given. Over the following 20 hr the patient's condition stabilized. In conclusion, we describe the use of a short-acting beta blocker to avoid compromising an impaired myocardium during a thyroid storm which we could stop if the patient's cardiac condition deteriorated. In addition, amrinone, a phosphodiesterase inhibitor, was our inotrope of choice as it does not act on the already blocked beta adrenergic system.

Adrenergic beta-Antagonists↗

PubMed1978

Correlation between systolic time intervals and roentgen findings in normal subjects and cardiopathic patients.

This study was designed to evaluate the usefulness of non-invasive parameters in the follow-up of cardiopathic patients without valvular cardiac diseases. In 49 patients suffering from heart disease we have studied the changes of radiologic cardiac measurements and systolic time intervals (STI) in the 4 functional classes of the NYHA classification, investigating also the existence of any relationship between these different parameters. Only the patients in the 3rd and the 4th functional classes showed significant changes in STI and radiologic measurements, as compared with the control group. Moreover, significant negative correlations have been observed between relative heart volume and LVET (r = 0.69, P less than 0.001) and LVETc (r = 0.82, P less than 0.001) and positive correlations between relative heart volume and PEP (r = 0.59, P less than 0.01) and PEP/LVET ratio (r = 0.75, P less than 0.001). These results, while confirming the close correlation between STI and cardiac performance, seem to demonstrate that relative heart volumetry is a fairly accurate index of the cardiac conditions in non-valvular heart diseases.

Adult↗

PubMed2005

Recommendations for the structure, organization, and operation of intensive cardiac care units.

Two major changes in patient characteristics and management occurred recently that demand distinctive alterations in the function of the intensive cardiac care unit (ICCU). These changes include the introduction of an early invasive strategy for the treatment of acute coronary syndromes, enabling early recuperation and shorter need for intensive care on the one hand, while the number of older and sicker patients requiring prolonged and more complex intensive care is steadily increasing. A task force of the European Society of Cardiology Working Group on Acute Cardiac Care was set to give a modern updated comprehensive recommendations concerning the structure, organization, and function of the modern ICCUs and intermediate cardiac units. These include the statement that specially trained cardiologists and cardiac nurses who can manage patients with acute cardiac conditions should staff the ICCUs. The optimum number of physicians, nurses, and other personal working in the unit is included. The document indicates the desired architecture and structure of the units and the intermediate cardiac unit and their relations to the other facilities in the hospital. Specific recommendations are also included for the minimal number of beds, monitoring system, respirators, pacemaker/defibrillators, and necessary additional equipment. The desired function is discussed, namely, the patients to be admitted, the length of stay, and the relocation policy. A uniformed electronic chart for ICCUs is advised, anticipating a common European database.

Coronary Care Units↗