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PubMed1986

Management of isolated systolic hypertension in the elderly.

Now that the benefits of treating diastolic hypertension in the elderly have been convincingly proved, attention is turning to the need for, and the choice of, treatment of isolated systolic hypertension in this age group. The hemodynamic mechanism differs in the elderly, whose isolated systolic hypertension is likely to be accompanied by reduced cardiac output, high peripheral resistance, and reduced plasma volume, whereas young people with similar blood pressure may have high cardiac output, normal peripheral resistance, and normal plasma volume. Increased risk of cardiovascular morbidity and mortality and the importance of reducing cardiac workload in older persons, are significant factors in the need for reduction of systolic pressure. After a good history and physical examination, and a careful check to ascertain that the elevated pressure is measured accurately, elderly patients can begin stepped-care therapy with a diuretic such as hydrochlorothiazide or chlorthalidone. The considerable dangers of a sudden drop in blood pressure can be avoided by giving small initial doses. Methyldopa or clonidine is recommended for step two; the third step can be hydralazine. Side effects, especially in the elderly, should be monitored carefully.

Adult↗
PubMed2001

Hypertension in obesity.

AIM: To review various topics regarding the relationship between obesity and hypertension. DATA SUMMARY: Obesity is a widespread and increasingly prevalent condition associated with a large number of comorbid diseases, one of the most important of which is obesity-induced hypertension (HTN). The association between obesity and HTN has been well documented in most racial, ethnic and socio-economic groups, although the relationship between body mass index (BMI) and blood pressure values depends on age, gender, type of obesity and race differences. Obesity-induced HTN has some unique characteristics that differ from those observed in lean hypertensive patients. The hemodynamic profile of obese subjects is characterised by high cardiac output, high plasma and total blood volume, and inappropriately normal to total peripheral resistance. Clinically, hypertensive obese subjects are more likely to develop left ventricular hypertrophy and kidney damage than their lean counterparts. Various common factors are involved in establishing sodium retention and vascular resistance and may be critically influenced by the neurobiological/genetic mechanisms leading to obesity, in which insulin, leptin and the adrenergic system play major roles. Obesity is one of the main causes of therapeutic failure, and a number of studies have demonstrated that obese subjects need more antihypertensive drugs than sex and age-matched lean hypertensives. Long-term dietary treatment, consisting of a moderate restriction of energy and salt intake, is the most effective and safe treatment for obesity-associated HTN. The use of treatments other than calorie restriction should be considered with caution. Drugs that increase energy expenditure or reduce appetite may variably increase blood pressure (BP) and are unsuitable for hypertensive subjects. There do not seem to be any clear differences in the efficacy of the various antihypertensive drug classes. The clustering of cardiovascular risk factors other than HTN needs to be taken into account when choosing antihypertensive treatment for obese subjects. CONCLUSIONS: Obesity is a highly prevalent condition that causes or exacerbates many health problems including HTN. Combined interventions at different levels can help in losing weight and therefore reduce the cardiovascular risk, morbidity and mortality associated with obesity.

Age Factors↗
PubMed1986

Evidence of early changes of the brachial artery circulation in borderline hypertension.

Quantitative evaluation of brachial artery diameter and blood flow (pulsed Doppler velocimetry) was carried out in nine normal subjects and 24 borderline hypertensive patients of the same age. The analysis of patients according to their value of cardiac index compared with the normal mean value plus 2 SD (standard deviation) enabled us to subdivide the patients into those with normal cardiac output and those with high cardiac output of similar age and pressure. Brachial artery diameter and flow were not different in patients with normal output and in normal controls, but were higher in patients with high output than in normal controls (p less than 0.05; p less than 0.01) and lower in patients with normal output than those with high output (p less than 0.01). These results demonstrate a nonhomogeneous pattern of the brachial artery of patients with borderline hypertension. Patients with normal cardiac output exhibited a trend to vasoconstriction, while patients with high cardiac output had a strong dilatation of the brachial artery.

Adult↗
PubMed2002

[Acute cardiovascular beriberi (shoshin-beriberi)].

Beriberi (BB), thiamine deficiency, has been described in the Asian literature in the 17th century and is characterized by peripheral neuropathy and muscle weakness, also called "dry" beriberi (BB) to differentiate it from "wet" BB, with essentially cardiovascular manifestations. Wet can be either "classic" wet BB in which signs and symptoms of right-sided heart failure with normal or high cardiac output are the presenting features or the "shoshin" BB variant with severe biventricular failure and metabolic acidosis, which must be treated early to prevent the rapid development of low cardiac output failure and sudden death. In this case, we report a 58 year old alcoholic woman who developed dyspnea, oliguria, edema, cardiac failure with high output, metabolic acidosis, renal tubular dysfunction and serum lactate level of 5.6 mEq/L. Neurological examination revealed peripheral neuropathy in the lower legs and cognitive alteration. She was treated with a loading dose of 100 mg of intravenous thyamine and responded with a marked increase in urine output, correction of acidosis, reduction in pulmonary-capillary wedge pressure and a change of the hemodynamic pattern. We conclude that shoshin-BB is uncommonly encountered but not widely recognized. In lactic acidosis and/or hyperdynamic circulation without any other apparent etiology in patients with possible vitamin B1 deficiency, the diagnosis of BB must be considered and thiamine should be administered.

Acidosis, Lactic↗
PubMed1988

Pathogenesis of sodium and water retention in high-output and low-output cardiac failure, nephrotic syndrome, cirrhosis, and pregnancy (2)

This article has analyzed the pathogenesis of sodium and water retention in several circumstances. The initiator of retention has been proposed to be either a fall in cardiac output (e.g., low-output cardiac failure and vasoconstrictor hypovolemic nephrotic syndrome) or peripheral arterial vasodilatation (e.g., high-output cardiac failure, cirrhosis, arteriovenous fistula, and pregnancy). In the only state discussed, in which the kidney is diseased and not merely responding to extrarenal reflexes--i.e., nephrotic syndrome--intrarenal mechanisms may predominate and lead to expansion of the arterial vascular tree and suppression of the renin-angiotensin-aldosterone system (i.e., hypervolemic nephrotic syndrome). Otherwise, when kidneys are healthy, either a fall in cardiac output or peripheral arterial vasodilatation may diminish arterial vascular filling and thereby initiate a series of hemodynamic and hormonal events that result in renal sodium and water retention (Fig. 7). Finally, the approach presented in this article should be considered to be a vantage point from which to evaluate states of sodium and water retention, but not to be an exclusive position.

Animals↗
PubMedDate not supplied

Hemodynamics in sepsis.

Hemodynamics in sepsis change as sepsis develops. Initial hemodynamics of sepsis often are much different from later stages of sepsis, shifting from low cardiac output states to high cardiac output states. Tissue oxygenation also changes with initial mixed venous oxyhemoglobin (Svo2) or central venous oxyhemoglobin (Scvo2) levels below normal, with later stages reflecting high values. These changes occur as sepsis progresses, producing a marked disturbance in capillary flow and tissue oxygenation. Treatments for these changes in sepsis are different, making the identification of the hemodynamic state essential to optimally treat the patient. Fortunately, hemodynamic monitoring techniques are markedly improved from older techniques such as the pulmonary artery catheter. With noninvasive techniques such as esophageal and external Doppler for measuring hemodynamics, clinicians beyond the intensive care unit can make hemodynamic assessments that were not possible until just recently. This improved assessment should make it much easier to properly identify sepsis and initiate appropriate treatments in a timely manner.

Blood Flow Velocity↗
PubMed1982

Hyperdynamic severe intravascular sepsis depends on fluid administration in cynomolgus monkey.

A new model of high cardiac output septic shock in primates is presented that includes hemodynamic and metabolic effects of separate and combined infusions of normal saline and live Escherichia coli. In monkeys receiving ketamine anesthesia, cardiac output (QT) increased with saline loading but not significantly with bacterial infusion, and bacterial infusion without saline never significantly increased QT. Depressed oxygen consumption (VO2) was reversed with saline loading. In spite of continuing E. coli infusion, radiolabeled microspheres showed no increase in systemic anatomic shunt when QT was elevated. It is perceived that the tissue dysfunction associated with sepsis, which is called septic shock, and elevation of cardiac output are related only indirectly. High cardiac output only reflects an adequate volume status in a stressed individual; some of the afferent stress signals can be related to the septic state, but no specific or direct relationship is involved. In general, shock as indicated by a depression of VO2 does not appear to occur when QT is increased.

Animals↗
PubMed2002

Angiographic features of rapidly involuting congenital hemangioma (RICH).

Rapidly involuting congenital hemangioma (RICH) is a recently recognized entity in which the vascular tumor is fully developed at birth and undergoes rapid involution. Angiographic findings in two infants with congenital hemangioma are reported and compared with a more common postnatal infantile hemangioma and a congenital infantile fibrosarcoma. Congenital hemangiomas differed from infantile hemangiomas angiographically by inhomogeneous parenchymal staining, large and irregular feeding arteries in disorganized patterns, arterial aneurysms, direct arteriovenous shunts, and intravascular thrombi. Both infants had clinical evidence of a high-output cardiac failure and intralesional bleeding. This congenital high-flow vascular tumor is difficult to distinguish angiographically from arteriovenous malformation and congenital infantile fibrosarcoma.

Angiography, Digital Subtraction↗
PubMed1982

Blood pressure and haemodynamics in teenagers.

It has been suggested that a hyperkinetic circulatory state, with high cardiac output, causes high blood pressure in childhood and, secondarily, in adulthood. We studied blood pressure and cardiac output in 319 subjects aged 15 to 19. Blood pressure was measured with an automated device; cardiac output was estimated by M-mode echocardiography and indexed by body surface area. The distribution of cardiac output was stratified using quartiles. Mean arterial pressure was virtually constant over these strata, with boys and girls showing essentially the same pattern. Linear regression of mean arterial pressure on cardiac output yielded a coefficient which was not significantly different from zero. A history of high blood pressure in the parents was positively associated with mean arterial pressure, but unrelated to cardiac output, in the offspring. This evidence does not support the hypothesis that the hyperkinetic circulatory state causes high blood pressure in childhood; rather, raised blood pressure in adolescents appears to relate to increased peripheral vascular resistance. Therefore, our findings lend support to the view that change in blood pressure over time is caused by a gradual increase in peripheral resistance beginning early in life.

Adolescent↗
PubMed1987

Haemodynamic basis of early modifications of the large arteries in borderline hypertension.

Quantitative evaluation of brachial artery diameter, blood velocity and flow (pulsed Doppler velocimetry) and of forearm arterial compliance (FAC)--mathematical analysis of the simultaneous diastolic pressure and flow according to a first-order arterial model--was carried out in 10 normotensive controls, and in 23 borderline hypertensive patients, of the same age. Using a value of 2 standard deviations above the average cardiac index of 20 normotensive subjects, enabled us to classify 12 patients as having a normal cardiac output and 11 patients as having a high cardiac output. Each group was of similar age and pressure. FAC was lower in patients with a normal cardiac output than in normal controls (P less than 0.01) and also lower than in patients with high output (P less than 0.01). Brachial artery diameter and flow were higher in patients with high output than in normal controls (P less than 0.01, P less than 0.001) and also higher than in patients with a normal output (P less than 0.001). A positive correlation (r = 0.55; P less than 0.01) was found between heart rate and brachial artery diameter in the 23 patients. These results demonstrate a non-homogenous pattern of brachial artery characteristics of patients with borderline hypertension. Patients with normal cardiac output exhibited a clear reduction of the distensibility of the forearm arteries while patients with high cardiac output had strong dilation of the brachial artery.

Adult↗
PubMed2005

Liver transplantation for cardiac failure in patients with hereditary hemorrhagic telangiectasia.

Liver involvement in hereditary hemorrhagic telangiectasia may lead to high-output cardiac failure. Few data have been reported on orthotopic liver transplantation (OLT) for these patients. In this paper, we describe two patients treated by OLT as a salvage procedure for cardiac failure, and we review literature on this subject. Our two patients resumed normal cardiac function after OLT. This procedure appears to be a promising therapy with good long-term results despite dissection difficulties encountered due to the collateral arterial network reorganization.

Angiography↗
PubMed1999

Cardiac effects of persistent hemodialysis arteriovenous access in recipients of renal allograft.

In hemodialysis patients, large arteriovenous (AV) fistulas for vascular access may cause ventricular hypertrophy and high-output cardiac failure. The long-term cardiac consequences of functional AV fistulas in renal transplant patients are unclear. A precise knowledge of these consequences is important to decide if and when such fistulas should be closed in successfully transplanted patients. In this retrospective study including 61 stable renal transplant patients with adequate renal function (serum creatinine <2.0 mg/100 ml), echocardiography was performed in 39 patients with a functional AV fistula (group 1) and in 22 whose fistulas had been closed, for esthetic reasons, within 2 months postoperatively (group 2). The volume flow of the fistulas, measured in 22 randomly selected individuals of group 1, was 900 +/- 350 ml/min (range 500-1,600). Patients of group 1 were older (40 +/- 12 vs. 33 +/- 12 years, p < 0.05), had longer duration of the fistula (62 +/- 31 vs. 36 +/- 30 months, p < 0.05), higher body mass index (24 +/- 4 vs. 22 +/- 3 kg/m2, p < 0.05), systolic (154 +/- 24 vs. 138 +/- 18 mm Hg, p < 0.05) and diastolic (96 +/- 12 vs. 89 +/- 11 mm Hg, p < 0.05) blood pressure and increased left ventricular (LV) end-diastolic dimension (53 +/- 5 vs. 49 +/- 5 mm, p < 0.01). LV mass, cardiac index, ejection fraction and the proportion of patients with LV hypertrophy were comparable in the two groups. LV end-diastolic dimension was positively and independently influenced only by the presence of the AV fistula (p < 0.01) after adjusting for age, duration of the fistula, body mass index, systolic and diastolic blood pressure and the nature of the antihypertensive drugs used. In conclusion, the persistence of large, high-flow AV fistulas for prolonged periods of time had little impact on cardiac morphology and function of stable renal transplant patients with adequate renal function. The data do not support routine closure of these fistulas in all renal transplant patients.

Adult↗
PubMed1992

[The effect of a single dose of Bisoprolol on changes in blood pressure and hemodynamic indicators in patients with mild hypertension].

The authors administered to 10 patients with mild hypertension a single dose of 10 mg bisoprolol (Concor-Merck) during bioimpedance control of changes of the cardiac index and peripheral vascular resistance after an interval of 3 and 24 hours following administration of the drug. In all patients administration of the drug led to a statistically significant drop of the blood pressure. In patients with a high cardiac output (group A, n = 6) the decline of blood pressure was due to a blocked increment of the cardiac output and a slight block of the peripheral vascular resistance. In the group with a low cardiac output and high peripheral vascular resistance (group B, n = 3) the drop of the blood pressure was caused by peripheral vascular dilatation, the cardiac output was influenced minimally. Bisoprolol did not affect the left ventricular systolic function.

Bisoprolol↗
PubMed1999

[Vein of Galen aneurysmal malformation: multi-staged feeder clipping in two neonatal cases with intractable heart failure].

The authors reported the surgical experience of two cases of vein of Galen aneurysmal malformation in the newborn, whose congestive high-output cardiac failure was intractable. Along with the intensive care to clinical manifestations of the heart failure, multi-staged feeder clipping was carried out to decrease the high-flow shunt of the malformation. As stages going on, heart failure was relieved gradually and cathecolamines were weaned. Although certain retardation became apparent in both cases, they are showing satisfactory development in the long-term follow up. By the recent advancement of the embolization technique, the embolization appears to have already taken place the treatment of choice for this malformation. According to the neonatal evaluation score of Lasjaunias, the embolization would no longer be recommendation in neonates, whose general condition scored less than eight points. The authors believe, based on our two cases, that multi-staged feeder clipping is one of the effective modality of treatment in neonates of the vein of Galen aneurysmal malformation with severe multiorgan failure.

Cardiac Output, High↗
PubMed2001

Prenatal sonographic diagnosis of Klippel-Trénaunay-Weber syndrome with cardiac failure.

This report describes the prenatal sonographic diagnosis of a case of Klippel-Trénaunay-Weber syndrome. The sonographic appearance of this disorder was characterized by the presence of multiple distorted cystic areas involving the right leg and abdomen and cardiomegaly with early fetal heart failure. Despite the prenatal detection of the extensive cutaneous and visceral involvement, the infant died soon after birth of high-output cardiac failure and Kasabach-Merritt syndrome.

Abdomen↗
PubMed1991

Oxygen utilization, carbon dioxide elimination and ventilation during recovery from supine bicycle exercise 6 to 8 weeks after acute myocardial infarction.

The pattern of oxygen (O2) consumption (VO2), carbon dioxide (CO2) production (VCO2), ventilatory and metabolic responses during and in recovery from supine bicycle exercise was examined in 18 patients with recent myocardial infarction. An increase in VO2 with increasing work load was accomplished by proportional increases in both cardiac output and the arteriovenous O2 difference. During recovery, however, the arteriovenous O2 difference rapidly decreased below levels at rest, whereas VO2 and cardiac output remained elevated, indicating that VO2 during recovery further depended on relatively high cardiac output. The ratio of VCO2 to VO2 further increased after exercise, suggesting that such cardiac output contributed to the remaining high CO2 flow to the lung and therefore enhanced ventilation. Increased arterial catecholamines during exercise remained elevated for the first 5 minutes of recovery. Arterial lactate during this period continued to increase and resulted in profound metabolic acidosis, causing alveolar hyperventilation after exercise. These results suggest that during recovery from exercise, cardiopulmonary responses remain enhanced because of continuing high cardiac output, resulting in subsequent high CO2 flow to the lung and metabolic acidosis, and that this may be associated with profound fatigue or dyspnea after exercise.

Acidosis, Lactic↗
PubMedDate not supplied

Ventricular function in cirrhosis and portasystemic shunt: a two-dimensional echocardiographic study.

Cardiovascular alterations such as increased heart rate, high cardiac output, reduced systemic vascular resistance, and in most of the cases, increased contractility parameters have been recognized in patients with advanced liver disease. Some investigators define a cirrhotic cardiomyopathy as a hyperdynamic failure of the heart. Consequently, in patients with cirrhosis, the risk of developing further circulatory deterioration may be increased in situations which stress the cardiovascular system. After opening a portocaval shunt, it is expected that a large amount of blood will be distributed from the splanchnic to the pulmonary circulation and put a strain on the heart. This two-dimensional echocardiographic study was made in 30 patients with cirrhosis and in 20 patients who were chronically treated (range: 16 to 156 months) with portasystemic shunt for prevention of hemorrhage from esophageal variceal bleeding. Patients with portasystemic shunts revealed a change in hemodynamic pattern. There was a significant increase in the left ventricular end-diastolic volume index and also a slight increase in the left ventricular end-systolic index. Cardiac output remained high despite a significant decrease in heart rate due to an elevated left ventricular stroke volume index. The parameters of systolic ventricular performance were normal. In contrast to the acute opening of the portacaval shunt, the chronic shunt volume put no strain of clinical significance on the heart.

Adult↗