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PubMed2007

[The "broken heart" syndrome--a rare clinical phenomenon].

BACKGROUND AND OBJECTIVE: A clinical entity that mimics acute coronary syndrome with reversible left ventricular systolic dysfunction and is triggered by emotional stress was identified in 6 patients by screening a database of > 1000 patients with the ICD-10 coding of acute coronary syndrome. The search criteria were acute coronary syndrome, normal coronary anatomy, absence of coronary lesions and transient left ventricular dysfunction, triggered by emotional stress. PATIENTS AND METHODS: We analyzed 6 patients, who fulfilled the criteria of (1) acute substernal chest pain with ST-segment elevation and/or T-wave inversion; (2) absence of significant coronary arterial narrowing on angiography, (3) systolic dysfunction with abnormal regional wall motion ("apical ballooning") in the context of (4) severe psychological stress immediately before and triggering the cardiac events. RESULTS: The primary diagnosis for all 6 acutely ill patients accorded with the ICD-code of acute coronary syndrome. All patients had survived and eventually recovered with an LV ejection fraction of 60 +/- 5 %; P = 0.03 and had had recovered normal levels of physical activity at hospital discharge. Of note is the number of women of postmenopausal age. CONCLUSIONS: A transient cardiomyopathy triggered by major emotional stress may mimic an acute coronary syndrome but without significant coronary artery disease. This condition is characterized by reversible cardiac dysfunction and may be more frequent in women. It has a favorable clinical outcome.

Acute Disease↗

PubMed2002

Hemodynamic characterization of patients with severe emphysema.

In 120 patients with severe emphysema evaluated for participation in the National Emphysema Treatment Trial, pulmonary hemodynamics and ventricular function were assessed. Pulmonary function tests were (%predicted): FEV(1) = 27%; residual volume = 224.6%; diffusion capacity = 26.7%. In 90.8% of patients, end-expiratory pulmonary artery mean pressure was > 20 mm Hg; in 61.4%, end-expiratory wedge pressure was > 12 mm Hg. Cardiac index was normal. Mean pulmonary artery pressure correlated inversely with arterial PO(2), and severity of emphysema, and directly with wedge pressure. Multiple stepwise regression revealed that arterial PO(2) was not an independent predictor of mean pulmonary artery pressure. No correlation was found between indices of emphysema severity and PA pressures. Diastolic ventricular pressures were increased without evidence of systolic dysfunction. We conclude that (1) elevations of pulmonary vascular pressures are common, (2) pulmonary hypertension may be related to factors other than hypoxia, (3) pulmonary hypertension does not impair resting systemic O(2) delivery, and (4) elevated cardiac diastolic pressures do not represent systolic dysfunction.

Aged↗

PubMed2004

Clinical signs of heart failure are associated with increased levels of natriuretic peptide types B and A in children with congenital heart defects or cardiomyopathy.

AIM: To study whether natriuretic peptide types B (BNP) and A (ANP) reflect clinical signs of heart failure (CSHF) in children with congenital heart defects or cardiomyopathy resulting in different types of haemodynamic situations, such as pressure overload in coarctation of the aorta (CoA), volume overload in ventricular septal defect (VSD) or systolic dysfunction in dilated cardiomyopathy (DCM). METHODS: Blood samples for plasma P-BNP and P-ANP were taken before procedures during regular investigation from 26 children (9 CoA, 11 VSD and 6 DCM). The ordinary paediatric cardiologist performed the cardiac evaluation and the data were retrieved from medical charts. CSHF was considered positive if two of the following criteria were fulfilled: reduced physical capacity, feeding disorders, dyspnoea, tachypnoea, hepatomegaly and oedema. The statistical methods were non-parametric. RESULTS: 0/9 children with CoA, 5/11 with VSD and 6/6 with DCM had CSHF. In children with CSHF, P-BNP and P-ANP were higher, 263 ng l(-1) (range 47.5-1300) and 303 ng l(-1) (range 168-466), than in those without CSHF, 12.3 ng l(-1) (range 4.8-30.8) and 42.9 ng l(-1) (range 13.7-189), respectively (p < 0.001, Mann-Whitney U-test), irrespective of the diagnosis. The same relationship was also found in the group of children with VSD. CONCLUSION: Plasma levels of ANP and BNP increase in children with CSHF. This increase is seen irrespective of whether it is due to systolic dysfunction, as in children with DCM, or to a volume overload with a normal systolic function, as in children with VSD.

Adolescent↗

PubMed2001

[Tolerability and clinical effects of carvedilol in patients over 70 years of age with chronic heart failure due to left ventricular dysfunction].

BACKGROUND: A number of studies showed the improvement in left ventricular (LV) function and clinical outcome that carvedilol produces in patients with severe congestive heart failure (CHF). However, no data are available regarding beta-blocker treatment in older patients with CHF. The purpose of this study was to assess the tolerability and efficacy of carvedilol in patients > 70 years with CHF associated with LV systolic dysfunction. METHODS: Thirty-seven patients in NYHA functional class III-IV with LV ejection fraction < 45% and a mean age of 76 +/- 6 years were prospectively studied. They received carvedilol which was associated with conventional therapy for CHF (ACE-inhibitors + diuretics + digitalis). The changes over time in clinical and echocardiographic variables (evaluated at baseline and every 6 months) were compared with those of 23 patients treated with the sole conventional therapy. RESULTS: During a follow-up of 13 +/- 8 months, 5 patients interrupted carvedilol due to side effects (tolerability 87%). Among the 32 remaining patients, 8 died. NYHA functional class improved in the 56% of survivors, LV ejection fraction increased (30 to 42%, p = 0.0002), mitral regurgitation and pulmonary capillary wedge pressure markedly decreased (2.0 to 1.0, p = 0.0001, and 19 to 13 mmHg, p = 0.0004, respectively). None of these variables was changed at the end of follow-up in the control group. Mortality was similar between the carvedilol (25%) and control group (22%). CONCLUSIONS: In the very elderly patients with LV systolic dysfunction and CHF carvedilol is well tolerated and safe. The addition of this drug to conventional therapy for CHF provides an important improvement in functional class, LV function and hemodynamics.

Age Factors↗

PubMed2001

Increased levels of tissue plasminogen activator antigen and factor VIII activity in nonvalvular atrial fibrillation: relation to predictors of thromboembolism.

INTRODUCTION: Given that nonvalvular atrial fibrillation (AF)-associated stroke can be either cardioembolic or atherothrombotic, we investigated the relationships between nonvalvular AF and hemostatic factors reflecting intrinsic thrombogenic and atherogenic potentials (tissue plasminogen activator [t-PA] antigen, plasminogen activator inhibitor-1, and factor VIII activity). We also evaluated the clinical applicability of these hemostatic factors by examining whether AF subjects with established clinical or echocardiographic predictors of thromboembolism had higher levels of these factors. METHODS AND RESULTS: Of the 3,212 participants of a Chinese population-based study, 53 subjects (1.7%) with AF were identified. Among the hemostatic factors measured, t-PA antigen (median 12.8 vs 8.1 ng/mL; P < 0.01) and factor VIII activity (median 155% vs 133%; P < 0.05) were significantly higher in AF subjects after adjustment for age and sex. In multivariate analysis, features independently associated with t-PA antigen levels were AF, sex, body mass index, systolic blood pressure, total cholesterol, triglycerides, and left ventricular systolic dysfunction. Features independently associated with factor VIII activity levels included AF, age, and total cholesterol. Levels of both t-PA antigen and factor VIII activity were primarily elevated in AF subjects with predictors of thromboembolism (age > 75 years, hypertension, diabetes, and left ventricular systolic dysfunction), whereas in AF subjects with no thromboembolic predictors, plasma levels of hemostatic factors examined were similar to those without AF. CONCLUSION: We demonstrated that nonvalvular AF was independently associated with increased peripheral levels of t-PA antigen and factor VIII activity. Levels of both hemostatic factors were primarily elevated in AF subjects with predictors of thromboembolism. Whether these hemostatic factors are independently predictive of future thromboembolic events in AF patients requires further investigation.

Adult↗

PubMed2005

VALIANT (VALsartan In Acute myocardial iNfarcTion) trial.

Angiotensin-converting enzyme inhibitors (ACE-Is) are an evidence-based treatment for patients who after myocardial infarction (MI) present with either heart failure (HF) or left ventricular systolic dysfunction, or both. An alternative could be a more complete inhibition of the renin-angiotensin system through the blockade of the angiotensin type 1 receptors. The effect of valsartan or captopril, or the combination of the two in post-MI HF or systolic dysfunction or both, has been evaluated in the VALIANT (VALsartan In Acute myocardial iNfarcTion) trial. Total mortality and the combined secondary end point of cardiovascular death, MI or HF were not significantly different in the three groups after 24.7 months of follow-up. Valsartan was not inferior to captopril in terms of total mortality and cardiovascular death, MI and HF. Valsartan can be considered an alternative treatment to ACE-I in these patients.

Adult↗

PubMed1993

Echocardiography in chronic heart failure in the community.

A total of 128 patients from a single practice population who were receiving loop diuretics for treatment of presumptive cardiac failure were identified from prescribing data captured by the Medicines Monitoring Unit. A subgroup of 78 patients underwent echocardiography to determine the prevalence of true left ventricular systolic dysfunction in this population and the validity of the diagnosis of cardiac failure in primary care. A further 50 patients were studied to assess the workload generated by these patients for both primary health care and hospital services. The estimated prevalence of left ventricular systolic dysfunction was 0.84%, whereas 1.6% of the population received loop diuretics for this indication. A false-positive diagnosis occurred in 47% and was more likely in females (73%) than males (37%). Of all consultations 79% were seen by GPs, 14% as hospital out-patients and 7% as in-patients. Within the hospital general physicians have most contact with these patients. In summary chronic heart failure is common within the community, although the false-positive rate for diagnosis of this condition is high. GPs and general physicians treat the majority of these patients and should therefore receive continuing education regarding recent advances in this area. Echocardiography should be performed early in the management of all patients suspected of having cardiac failure.

Adult↗

PubMed2002

Resynchronization Therapy for Congestive Heart Failure.

Ventricular contraction is achieved by the coordinated electrical activation of the ventricles through the action of the cardiac conduction system. In the presence of left bundle branch block (LBBB) or interventricular conduction delay (IVCD), the ventricular contraction pattern is desynchronized and the stroke volume is reduced as a consequence. In patients with congestive heart failure (CHF) due to systolic dysfunction, the presence of LBBB or IVCD further degrades ventricular function, contributing directly to the severity of their CHF symptoms. Cardiac resynchronization therapy (CRT) through biventricular pacing relieves CHF symptoms and improves functional status in patients with medically refractory heart failure due to left ventricular systolic dysfunction and LBBB or IVCD. The benefits of CRT are due to improvement in the ventricular activation sequence, resulting in a more coordinated and efficient ventricular contraction. In addition to symptomatic benefits, available data support the hypothesis that CRT alters the natural history of CHF in patients with intraventricular conduction delay.

Journal Article↗

PubMed1996

Antihypertensive therapy reduces increased plasma levels of adrenomedullin and brain natriuretic peptide concomitant with regression of left ventricular hypertrophy in a patient with malignant hypertension.

We investigated the potential role of increased plasma adrenomedullin and brain natriuretic peptide (BNP) levels in a patient with malignant hypertension. A 51-year-old man was admitted to our hospital with a chief complaint of visual disturbance. His blood pressure was 270/160 mmHg on admission. Papillary edema associated with retinal bleeding was observed. Echocardiography revealed marked concentric left ventricular hypertrophy with mild systolic dysfunction. Plasma levels of adrenomedullin and BNP were markedly elevated. Antihypertensive therapy reduced the plasma levels of adrenomedullin in association with a concomitant decrease in blood pressure. The plasma level of BNP also decreased and regression of left ventricular hypertrophy and normalization of left ventricular systolic function were observed. Our findings suggest that adrenomedullin may be involved in the defense mechanism against further elevations in blood pressure in patients with hypertension and that the plasma level of BNP may reflect left ventricular systolic dysfunction, left ventricular hypertrophy, or both, in patients with severe hypertension.

Adrenomedullin↗

PubMed2001

[Plasma levels of neuropeptide Y i patients with current myocardial infarction].

Neuropeptide Y (NPY) has been recently characterised as one of the strongest circulating vasoconstrictor peptides, its elevated level may cause coronary artery spasm and increase of peripheral vascular resistance. All this contributes to ischemic myocardial damage and decrease of regional and global left ventricular function. The aim of the study was the examination of NPY plasma levels in patients with acute myocardial infarction (AMI) after thrombolytic therapy with or without reperfusion. The survey was made in 82 patients with AMI after thrombolytic therapy: 40 of them without reperfusion and 42 with reperfusion. The control group consisted of 20 healthy persons. Plasma levels of NPY were measured before thrombolysis, then 1, 3 and 5 days after, using a radioimmunologic method. All patients were treated with aspirin, glyceryl trinitrate and thrombolytic therapy (TT) with alteplase (r-TPA). In patients with AMI, NPY plasma levels were normal before and 1 day after TT, and were significant elevated 3 days after TT 5 days after TT, plasma NPY levels were still high in patients without reperfusion, but they decreased in patients with reperfusion. There was significant negative correlation between NPY level and left ventricular ejection fraction measured 5 days after AMI. During 30-days follow up systolic dysfunction of left ventricle with ejection fraction under 40% occurred in 21 patients and in 11 of them clinical symptoms of heart failure were observed. Using the multivariable regression analysis we showed that NPY concentration over 60 pg/ml is the independent factor leading to left ventricle systolic dysfunction. The results of our study suggest the contribution of NPY to the left ventricular remodeling after AMI.

Adult↗

PubMedDate not supplied

[Systolic and diastolic function of heart ventricles and their remodeling in adult patients with congenital heart disease in phase of Eisenmenger's syndrome].

55 patients with congenital heart diseases (CHD) in phase of Eisenmereger's syndrome (ES) (11 patients with ductus arteriosus (DA), 28--ventricular septal defect (VSD), 16--atrial septal defect (ASD)) at age of 14-53 (mean 29.7+/-3.2) were examined. Heart failure corresponded to I-II functional classes (NYHA) in 28 (50.9%) patients, III-IV--in 27 (49.1%). Diagnosis of ES was confirmed by ECG, Doppler-Echo-CG, catheterization and ventriculography. Moderate right ventricle systolic dysfunction was revealed and confirmed by its dilation and deterioration of inferior vena cava (IVC) (for 156.0% in comparision with healthy people, P<0.001) in patients DA and ASD collapse after inspiration. Unchanged indices of Vmax and Accmax in PA and IVC diameter showed good compensatory potential of RV. There was the initial stage of LV systolic dysfunction (decrease EF for 7.0%, Vmax for 16.7% and Accmax for 21.4%, P<0.05). Diastolic dysfunction of both ventricles in patients with ES is unidirectional and corresponds to relaxation type.

Adolescent↗

PubMed1983

Detection of left ventricular dysfunction in ambulatory subjects with the bedside Valsalva maneuver.

The bedside sphygmomanometric determination of the arterial pressure response during the Valsalva maneuver was incorporated into the routine physical examination of ambulatory subjects. Four distinct Valsalva responses were noted: ultrasinusoidal, sinusoidal, absent overshoot, and square wave. The absent overshoot response was further divided into positional and constant types--the latter consistently exhibiting this response regardless of body position. Correlation with resting left ventricular ejection fraction was obtained by radionuclide cineangiography in 200 patients, of whom 81 had left ventricular systolic dysfunction (ejection fraction less than 0.50). Significant differences in the mean left ventricular ejection fraction were found in subjects with an ultrasinusoidal response (0.65 +/- 0.11), sinusoidal response (0.55 +/- 0.15), constant absent overshoot response (0.37 +/- 0.18), and square wave response (0.16 +/- 0.04) to Valsalva maneuver. The sensitivity of an abnormal Valsalva response (absent overshoot or square wave responses) for the bedside detection of left ventricular systolic dysfunction was 69 percent, and the predictive value of an ultrasinusoidal Valsalva response for normal ejection fraction was 93 percent. It is concluded that the high predictive accuracy of the Valsalva maneuver makes this simple bedside technique a valuable method for assessing resting left ventricular function.

Ambulatory Care↗

PubMed2000

[Value of the Valsalva maneuver for evaluating systole heart function].

Many tests and examinations are used for diagnosing heart failure. Their accuracy tends to vary, echocardiography representing the gold standard. The Valsalva maneuver involves an easy-to-perform test for assessing the cardiac ejection fraction. The present study investigated the power of the Valsalva test in patients who received an echocardiography for various indications. A total of 153 patients were examined, some recruited from private practices, some from different hospitals. An echocardiographically measured left-ventricular ejection fraction of 45% was set as the limit value. 30 patients had an ejection fraction of less than 45%, signaling a relevant systolic dysfunction. The sensitivity of the Valsalva test for detecting impaired function was 70% and its specificity 72%. The positive predictive value was 39% and the negative predictive value 90%. This means that when the Valsalva test produces a normal result and the EKG is also normal, the likelihood that the patient has no relevant systolic dysfunction is very great. The Valsalva test is cost-effective, quick and easy to perform and useful for evaluating left-ventricular pump function.

Adolescent↗

PubMedDate not supplied

Radiofrequency catheter ablation of atrioventricular accessory pathways in 3 dogs with subsequent resolution of tachycardia-induced cardiomyopathy.

Incessant supraventricular tachyarrhythmias are known to result in myocardial dysfunction indistinguishable from idiopathic dilated cardiomyopathy by current testing methods. This tachycardia-induced cardiomyopathy (TICM), however, is uniquely reversible with adequate rhythm control. Two dogs were presented to The Ohio State University for incessant supraventricular tachycardia (SVT) and echocardiographic signs of dilated cardiomyopathy, later proven to be TICM. A 3rd dog presented for frequent paroxysms of SVT and syncope had echocardiographic signs of mild myocardial systolic dysfunction. All 3 dogs had inadequate rhythm control with multiple antiarrhythmic agents, and 1 dog suffered from recurrent left-sided congestive heart failure. Generalized cardiomegaly was found in 1 dog and left-sided dilatation without concurrent right-sided enlargement in 1 dog. Mild-to-severe left ventricular systolic dysfunction was confirmed echocardiographically in all dogs. A total of 4 atrioventricular accessory pathways (APs) were found during invasive electrophysiologic studies in these 3 dogs. All APs were successfully ablated with radiofrequency energy delivered through a thermistor-tipped catheter. Elimination of AP conduction, and thus orthodromic atrioventricular reciprocating tachycardia, resulted in resolution of all clinical and echocardiographic evidence of TICM in these dogs. This result confirms that the cardiomyopathy was, in fact, reversible TICM. All cardiovascular medications were discontinued, and no complications occurred during a 15-25-month follow-up period.

Animals↗

PubMed1990

Analysis of the early transmitral Doppler velocity curve: effect of primary physiologic changes and compensatory preload adjustment.

Left ventricular filling (as assessed by Doppler echocardiography) has previously been shown to depend in a complex fashion on ventricular diastolic function (compliance and relaxation) as well as other variables, such as atrial pressure and compliance, ventricular systolic function and mitral valve impedance. To study the effect of isolated physiologic alterations on individual Doppler indexes, a mathematic model of mitral flow was analyzed. By varying one physiologic variable at a time, it was shown that mitral velocity acceleration is affected directly by atrial pressure and inversely by the ventricular relaxation time constant, with relatively little impact of chamber compliance. Deceleration rate was directly influenced by mitral valve area, atrial pressure and ventricular systolic dysfunction and inversely affected by atrial and ventricular compliance relations, with little impact of relaxation unless it was so delayed as to be incomplete during deceleration. Peak velocity was directly affected most strongly by initial left atrial pressure, and lowered somewhat by prolonged relaxation, low atrial and ventricular compliance and systolic dysfunction. Strikingly different filling patterns emerged when the primary physiologic alterations were accompanied by simultaneous compensatory changes in atrial pressure designed to maintain stroke volume constant. Low ventricular compliance with preload compensation produced characteristic E waves with very short acceleration and deceleration times and high peak velocity. Thus, mathematic analysis of ventricular filling helps to explain the physical and physiologic basis for the transmitral velocity curve.

Blood Flow Velocity↗

PubMed2005

Peculiar aspects of cardiogenic embolism in patients with Chagas' cardiomyopathy: a transthoracic and transesophageal echocardiographic study.

OBJECTIVES: We sought to detect cardiac thrombi by transthoracic and transesophageal echocardiography in patients with Chagas' cardiomyopathy and to determine the relationship of these thrombi with left ventricular systolic function and with the presence of stroke. BACKGROUND: Thromboembolic events are a serious complication of Chagas' cardiomyopathy. Because most data come from autopsy studies, the prevalence of cardiac thrombi for patients who are clinically stable is unknown. METHODS: A total of 75 patients (52 men; mean age 48 +/- 13 years) with Chagas' cardiomyopathy were prospectively studied by transthoracic and transesophageal echocardiography and followed for 24 +/- 10 months. RESULTS: In all, 14 patients (19%) had a history of stroke at the time of enrollment and two had this complication at follow-up. Most patients (88%) were in New York Heart Association (NYHA) functional classes I and II and 9 (12%) were in classes III and IV. Mean ejection fraction was 40 +/- 13%. A total of 17 patients (23%) had left ventricular thrombus on transthoracic echocardiography and this finding was associated with a history of stroke ( P = .01). Apical aneurysm occurred in 35 patients (47%) and it was associated both with thrombus and stroke ( P = .04). Strokes were more frequent ( P = .04) among patients with mild systolic dysfunction (57% of patients with strokes were in NYHA I). Four patients (5%) had thrombi at the left atrial appendage, and one (1%) at the right atrial appendage. A total of 13 patients (17%) died at follow-up. CONCLUSIONS: Stroke was frequent in Chagas' cardiomyopathy and associated with mild systolic dysfunction and with intracardiac thrombi. These occurred mainly in the typical apical aneurysm of Chagas' disease.

Brazil↗

PubMed1996

Rationale, background, and design of the randomized angiotensin receptor antagonist--angiotensin-converting enzyme inhibitor study (RAAS).

The randomized angiotensin receptor antagonist--angiotensin converting enzyme (ACE)--Inhibitor Study (RAAS) was designed to test the hypothesis that the addition of an angiotensin II type 1 receptor blocking agent, losartan 50 mg/day, to an ACE-inhibitor, enalapril 10 mg twice a day (group 1), will be more effective than standard-dose enalapril 10 mg twice a day (group 2) or high-dose enalapril alone 20 mg twice a day (group 3), in blocking the activation of the renin angiotensin aldosterone system in patients with heart failure and left ventricular systolic dysfunction. The addition of an angiotensin II type 1 receptor blocking agent to an ACE inhibitor would theoretically block ACE as well as non-ACE-dependent angiotensin II formation while maintaining the potential beneficial effect of ACE inhibitor-induced bradykinin formation. One hundred twenty patients with left ventricular systolic dysfunction and moderate to severe heart failure despite treatment with an ACE inhibitor will be randomized to 1 of the 3 groups and followed for 6 weeks, with an optional long-term week extension to determine the safety and tolerability of the combination of losaratan and enalapril, its effectiveness in preventing rest and exercise-induced neurohumoral activation (plasma norepinephrine, N-terminal proatrial natriuretic factor, angiotensin II, and aldosterone), as well as quality of life and exercise performance (6-minute walk test).

Angiotensin Receptor Antagonists↗

PubMed2002

[Dilated cardiomyopathy and autoimmunity: an overview of current knowledge and perspectives].

The diagnosis of idiopathic dilated cardiomyopathy is assigned to patients with left ventricular systolic dysfunction and dilatation in the absence of any other documented cause. Idiopathic dilated cardiomyopathy is presumed to have a multifactorial origin, possibly including autoimmune mechanisms. We reviewed the current state of knowledge of this topic, including a pathophysiological hypothesis postulating a relation between an autoimmune process and sympathetic over-stimulation and systolic dysfunction. The implications for therapy are considered in the light of experience with other autoimmune diseases. The results of immunosuppressant treatment and preliminary experiences with immunoadsorption are reviewed and their future perspectives are discussed.

Adjuvants, Immunologic↗