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Diabetes related cardiomyopathy time dependent echocardiographic evaluation in an experimental rat model.

Type I diabetes is associated with a unique form of cardiomyopathy in the absence of atherosclerosis. The mechanisms involved in this phenomenon are not defined, but in humans this is associated with initial diastolic dysfunction followed by altered contractile performance. A relevant animal model would provide opportunities for mechanistic studies and experimental therapeutics, but none have been previously established for this unique form of cardiac pathophysiology, particularly with respect to clinically relevant and time-dependent diastolic and systolic assessments. Here we tested the hypothesis that the streptozotocin rat model mimics human phenomena with respect to time-dependent diastolic and systolic performance deficits, and investigated a role for cardiac hypertrophy and/or fibrosis. Streptozotocin was dosed 65 mg/kg i.p. and cardiac performance was assessed longitudinally for 56 days using noninvasive echocardiographic techniques. Significant hyperglycemia was detected within 3 days and remained elevated throughout the study (p<0.05). Significant reductions in HR and diastolic performance (transmitral flow velocities and slopes) were observed within 3 days relative to age matched controls, and these reductions progressed throughout the 56 day study. In contrast, statistically significant systolic dysfunction (LV fractional shortening, cardiac output) and LV dilation were detected only after 35 days. Increases in LV size and/or extent of fibrosis were not observed at any time. These results demonstrate the value of echocardiographic methods for time-dependent diastolic and systolic assessments in rodent models. Furthermore, diastolic dysfunction precedes contractile abnormalities in the streptozotocin model, similar to events that occur in humans.

Analysis of Variance↗

Level of left ventricular dysfunction in endomyocardial biopsy-proven myocarditis.

The level of myocardial functional impairment in the course of myocarditis still remains associated with controversial data. However, many investigators agree that there is a significant heart failure during myocarditis and a large number of studies suggest development of global chronic or acute heart failure. The objective of this study was to establish haemodynamic parameters as descriptors of the level of myocardial systolic and diastolic impairment. From 131 investigated patients, 95 were assigned to the study group and 36 to the control group. All patients underwent right and left heart catheterization. A group of patients underwent EMB (endomyocardial biopsy) of the right ventricle. According to the Dallas Criteria, patients were divided into three groups: active myocarditis with fibrosis, active myocarditis without fibrosis and borderline myocarditis. The following haemodynamic parameters were evaluated: left ventricle EF (ejection fraction), cardiac index and end diastolic pressure of the left ventricle. EF, which reflects left ventricular systolic impairment, showed a difference related to the control group, while there was no difference in cardiac index between the groups. Diastolic dysfunction (end diastolic pressure of the left ventricle) was noted in the group with active myocarditis, but not in the group with borderline myocarditis.

Adult↗

Doppler analysis of pulmonary venous flow profiles in orthotopic heart transplant recipients: a comparison with mitral flow profiles and atrial function.

Previous Doppler studies of transmitral flow profiles in heart transplant recipients suggested left ventricular (LV) diastolic dysfunction. The influence of left atrial filling and emptying on mitral Doppler profiles in heart transplant recipients has not been studied systematically. In the present study, pulmonary venous flow profiles, mitral flow profiles, left atrial area change and mitral annulus motion were analyzed in 20 orthotopic heart transplant recipient and 20 control subjects by transthoracic and transesophageal echocardiography and Doppler. Mitral flow profiles revealed a "restrictive" pattern with a high early-to-late diastolic flow velocity ratio in transplant patients (2.16 +/- 0.52 vs. 1.30 +/- 0.25, p < 0.0001), which was mainly due to a reduced late diastolic maximum mitral flow velocity (32.6 +/- 8.3 vs. 51.6 +/- 12.4 cm/s, p < 0.0001). Left atrial area change (35.9 +/- 13.9 vs. 58.1 +/- 17.0%, p < 0.0006) and mitral annulus motion (9.2 +/- 3.3 vs. 12.2 +/- 2.0%, p < 0.05) were reduced in transplant recipients, compared to controls. Pulmonary venous flow parameters in transplant recipients were markedly altered during systole, when pulmonary venous flow parameters are influenced primarily by atrial function rather than by diastolic LV properties: peak systolic flow velocity (45.5 +/- 8.2 vs. 62.3 +/- 14.0 cm/s, p < 0.001), maximum flow velocity ratio (0.87 +/- 0.19 vs. 1.45 +/- 0.33), time velocity integral of pulmonary venous flow during systole (9.3 +/- 2.3 vs. 17.1 +/- 4.0 cm, p < 0.001) and the systolic fraction of the time velocity integral (52.6 +/- 10.8 vs. 68.5 +/- 6.8%, p < 0.001) were lower in heart transplant recipients than in controls. These findings are compatible with atrial dysfunction and reduced mitral annulus motion. The results of this study indicate that LV diastolic dysfunction is not the only possible cause of altered transmitral Doppler profiles in heart transplant recipients. Atrial abnormalities represent a major contributing factor to altered mitral and pulmonary venous flow patterns. Analysis of transmitral Doppler profiles alone are therefore not adequate for analysis of diastolic LV function in heart transplant recipients.

Adult↗

The clinical diagnosis of heart failure in older patients.

OBJECTIVE: To review the differences in presentation and clinical manifestation of heart failure in older and younger patients and to determine if these differences influence the ability to diagnose the disorder clinically. Based on this information, an approach to diagnosing heart failure in older patients is provided. DATA SOURCE: Scientific reports regarding heart failure in both the general population and the geriatric population were identified from repeated searches of MEDLINE data base and citations from appropriate articles. DATA EXTRACTION AND SYNTHESIS: Relevant data were obtained from articles, with special importance placed on studies designed to examine older patients exclusively or as a subgroup in a larger study. Review of data pertaining to clinical characteristics and presentation of heart failure was performed, with emphasis on comparing the characteristics between age groups. Specific cardiac diseases that cause ventricular impairment in older patients were assessed, and the importance of systolic versus diastolic dysfunction in this age group was analyzed. CONCLUSION: Clinical diagnosis of heart failure in older patients may be difficult because of the absence of typical symptoms and physical findings. When present, the symptoms and signs may be mistakenly diagnosed as caused by concomitant disorders or aging changes. In other older patients, the symptoms and signs will be obscured by the presence of aging changes or the presence of other diseases. As a result of these difficulties, the initial diagnosis of heart failure in older patients is made later in the course of the cardiac disease process; older patients will be more unstable, and secondary preventive therapies may be of less benefit than in younger patients with the disorder. Though clinically difficult, the differentiation between systolic and diastolic ventricular dysfunction is mandatory in all older patients with heart failure.

Age Factors↗

A comparative serial echocardiographic analysis of cardiac structure and function in rats subjected to pressure or volume overload.

Heart failure is a leading cause of death that is reaching epidemic proportions. It is a clinical syndrome attributable to a multitude of factors that begins with a compensatory response known as hypertrophy, followed by a decompensatory response that eventually results in failure. Heart failure can be triggered when the heart is subjected to extended periods of pathological pressure overload (PO) or volume overload (VO). To date there have been no comparative serial echocardiographic studies outlining the progression of hypertrophy in PO versus VO rats. We hypothesized that PO or VO would induce differential cardiac remodeling leading to contractile dysfunction with subsequent heart failure. To address this hypothesis we used echocardiography to study the serial progression of heart structure and function in rat models of both PO- and VO-induced hypertrophy. PO or VO were induced by performing abdominal aortic banding or aortocaval shunt procedures, respectively, while cardiac structure and function were assessed in both models by M-mode and Doppler echocardiography at key time intervals. PO rats showed progressive wall thickening consistent with concentric hypertrophy, while VO rats showed marked left ventricular dilatation consistent with eccentric hypertrophy. Systolic dysfunction occurred early in VO compared to PO. Diastolic dysfunction was evident in PO, while VO showed signs of enhanced diastolic function. PO and VO induced differential changes in cardiac structure and function during the progression of compensated hypertrophy to decompensated heart failure.

Animals↗

Influence of autonomic neuropathy upon left ventricular dysfunction in insulin-dependent diabetic patients.

BACKGROUND: Diabetic cardiomyopathy is a well-defined complication of diabetes that occurs in the absence of ischemic, vascular, and hypertensive disease. HYPOTHESIS: The study was undertaken to test the relationship among autonomic neuropathy (AN), 24-h blood pressure (BP) profile, and left ventricular function. METHODS: Nineteen type-1 diabetic patients underwent autonomic tests and echocardiographic examination. Patients were divided according to the presence (AN+) or absence (AN-) of AN. RESULTS: In the AN+ group (n = 8), the E/A ratio at echo was lower than in the AN- group (n = 11) (1.1 +/- 0.3 vs. 1.6 +/- 0.3; p < 0.005). Systolic and diastolic BP reductions during sleep were smaller in the AN+ than in the AN- group (6.6 +/- 6.6 vs. 13.0 +/- 4.3%; p < 0.03 for systolic and 12.8 +/- 6.8 vs. 20.0 +/- 4.0% for diastolic BP reduction; p < 0.03, respectively). Considering all patients, the E/A ratio correlated inversely with awake diastolic BP (r - 0.63; p = 0.005); sleep systolic BP (r - 0.48; p = 0.04), and sleep diastolic BP (r - 0.67; p = 0.002). The AN correlated with diastolic interventricular septum thickness (r 0.57; p = 0.01), sleep systolic BP (r 0.45; p = 0.05), sleep diastolic BP (r 0.54; p = 0.02), and correlated inversely with systolic and diastolic sleep BP reduction (r - 0.49; p = 0.03 and r - 0.67; p = 0.002, respectively). Finally, E/A ratio and AN score correlated between themselves (r - 0.6; p = 0.005). CONCLUSION: Our results suggest that left ventricular diastolic dysfunction may be detected very early in type-1 diabetic patients with AN. Parasympathetic lesion and nocturnal elevations in BP could be the link between AN and diastolic ventricular dysfunction.

Adult↗

Improved myocardial ischemic tolerance by contractile inhibition with 2,3-butanedione monoxime.

Contracture of the arrested myocardium during prolonged storage of the heart results in both systolic and diastolic dysfunction, and is a major limitation to extended preservation. We studied the effects of a reversible contractile inhibitor, 2,3-butanedione monoxime (BDM), on myocardial ischemic tolerance. Isolated rabbit hearts were flushed with University of Wisconsin (UW) solution with and without 30 mmol/L BDM and 1 mmol/L CaCl, stored at 4 degrees C for 24 hours, and subsequently reperfused for 60 minutes. Left ventricular pressure-volume relationships and adenine nucleotide content were determined before reperfusion. Left ventricular systolic pressure, diastolic volume, and adenine nucleotide content were measured after reperfusion. Hearts stored in UW solution underwent contracture and adenosine triphosphate (ATP) depletion during storage, and exhibited systolic dysfunction, impaired diastolic relaxation, and poor ATP regeneration upon reperfusion. The addition of calcium worsened contracture and ATP depletion (p < 0.005) and slightly improved function and ATP regeneration (p = not significant). Hearts stored in the presence of BDM experience no contracture during storage; ATP was preserved (10.7 versus 15.7 nmol/mg; p < 0.05), and left ventricular systolic pressure and ATP content recovered to 74% and 93% of control on reperfusion, respectively (p < 0.005). Left ventricular diastolic volume remained depressed, however, although less than with UW solution (0.87 versus 0.45 mL; p < 0.001). When both BDM and calcium were included in the UW solution, calcium-stimulated ATP hydrolysis and contracture were prevented, left ventricular systolic pressure returned to 87% of control, and left ventricular diastolic volume and ATP content returned to control levels.(ABSTRACT TRUNCATED AT 250 WORDS)

Adenine Nucleotides↗

Clinical significance of noninvasive assessment of left ventricular diastolic function by Doppler echocardiography.

Transmitral flow velocity pattern obtained by the pulsed Doppler technique reflects left ventricular (LV) diastolic function, but an increase in left atrial pressure pseudonormalizes the flow pattern and masks diastolic dysfunction. We propose an index to assess LV diastolic function using color M-mode Doppler echocardiography and the base-line shift technique. This index, flow propagation velocity, represents the average velocity of early diastolic LV filling flow from the mitral orifice to mid-ventricle. In patients with ischemic heart disease and dilated cardiomyopathy including those with pseudonormalized transmitral flow pattern, flow propagation velocity had a good correlation with the time constant of early diastolic LV pressure decay (Tau), indicating that flow propagation velocity is a useful noninvasive parameter of diastolic function which does not pseudonormalize. We also found a significant correlation between flow propagation velocity and Tau in hypertrophic cardiomyopathy patients in contrast to inadequate or no correlation between each of the conventional parameters and Tau. In addition, our recent data suggest that flow propagation velocity was distinctly decreased even in the patients with hypertension who did not show significant increase in LV mass index. Flow propagation velocity is a unique noninvasive parameter of LV diastolic function, which can sensitively and accurately detect the diastolic impairment in patients with different types of cardiac diseases with various loading conditions.

Blood Flow Velocity↗

Glycogen synthase kinase-3beta regulates growth, calcium homeostasis, and diastolic function in the heart.

Glycogen synthase kinase (GSK) 3beta is a negative regulator of stress-induced cardiomyocyte hypertrophy. It is not clear, however, if GSK-3beta plays any role in regulating normal cardiac growth and cardiac function. Herein we report that a transgenic mouse expressing wild type GSK-3beta in the heart has a dramatic impairment of normal post-natal cardiomyocyte growth as well as markedly abnormal cardiac contractile function. The most striking phenotype, however, is grossly impaired diastolic relaxation, which leads to increased filling pressures of the left ventricle and massive atrial enlargement. This is due to profoundly abnormal calcium handling, leading to an inability to normalize cytosolic [Ca2+] in diastole. The alterations in calcium handling are due at least in part to direct down-regulation of the sarcoplasmic reticulum calcium ATPase (SERCA2a) by GSK-3beta, acting at the level of the SERCA2 promoter. These studies identify GSK-3beta as a regulator of normal growth of the heart and are the first of which we are aware, to demonstrate regulation of expression of SERCA2a, a critical determinant of diastolic function, by a cytosolic signaling pathway, the activity of which is dynamically modulated. De-regulation of GSK-3beta leads to severe systolic and diastolic dysfunction and progressive heart failure. Because down-regulation of SERCA2a plays a central role in the diastolic and systolic dysfunction of patients with heart failure, these findings have potential implications for the therapy of this disorder.

Animals↗

High-dose 17beta-estradiol treatment prevents development of heart failure post-myocardial infarction in the rat.

OBJECTIVES: Prognosis of heart failure remains poor despite therapeutic advances, such as angiotensin converting enzyme inhibition or beta-receptor blockade. Thus, more effective forms of treatment are urgently needed. Since estrogens have been shown to modulate migration and proliferation of cardiac fibroblasts and to modulate the expression of estrogen receptors of cardiomyocytes we examined whether high-dose estrogen treatment can affect post-myocardial infarction left ventricular remodeling. METHODS: Female rats were treated with 17beta-estradiol (7.5 mg/90 d) or placebo for ten weeks, starting two weeks prior to experimental myocardial infarction. Eight weeks after infarction, in vivo echocardiographic and hemodynamic measurements as well as isolated heart perfusion were performed. RESULTS: In vivo, chronic estrogen treatment almost completely prevented the development of all signs of heart failure that occur in untreated infarcted hearts, such as increased left ventricular diameters (dilatation), reduced fractional shortening (systolic dysfunction) or increased left ventricular end-diastolic pressure (diastolic dysfunction). In vitro, the right- (indicating structural dilatation) and downward (indicating left ventricular dysfunction) shift of left ventricular pressure-volume curves occurring in untreated infarcted hearts was completely prevented by estrogen. CONCLUSIONS: High dose estradiol treatment prevented development of post-MI remodeling, as assessed by in vivo and in vitro parameters of LV dysfunction. Estrogen may hold the potential of becoming a new form of heart failure treatment.However, the mechanisms responsible for this striking and unexpected beneficial action of estrogen in heart failure remain to be elucidated.

Animals↗

Local neurohumoral regulation in the transition to isolated diastolic heart failure in hypertensive heart disease: absence of AT1 receptor downregulation and 'overdrive' of the endothelin system.

OBJECTIVE: Although isolated diastolic heart failure with preserved left ventricular (LV) systolic function frequently occurs, regulation of local neurohumoral factors in the transition from diastolic dysfunction without signs of heart failure to diastolic failure, a target for therapeutic strategy, remains to be clarified, partly because of a lack of animal models. Our laboratory recently demonstrated that Dahl-Iwai salt-sensitive (Dahl-S) rats fed on a high-salt diet since 7 weeks of age develop hypertension followed by compensated LV hypertrophy at 13 weeks and transition to isolated diastolic heart failure at 19 weeks. METHODS: Gene expression of the components of the renin-angiotensin system, endothelin (ET) system and natriuretic peptide system in the left ventricle was investigated in the transition to isolated diastolic heart failure in this model. RESULTS: The compensated ventricular hypertrophy was associated with slight increases in angiotensin-converting enzyme (ACE) and angiotensin II type-1a (AT1a) receptor mRNA levels. Although preproET-1 (ppET-1) and ET-converting enzyme-1 (ECE-1) mRNA levels were not increased, mRNA levels of ET type-A (ETA) and ET type-B (ETB) receptors were increased. Atrial natriuretic peptide (ANP) mRNA level increased, but not brain natriuretic peptide (BNP) mRNA level. At the decompensated failing stage (at 19 weeks), ACE mRNA level further increased without downregulation of ATla receptor mRNA level. The mRNA levels of ppET-1 and ECE-1 increased with persistent upregulation of mRNA levels of ETA and ETB receptors, and immunohistochemical staining for ET-1 was found at endothelial cells and myocytes. BNP mRNA level increased with a further increase in ANP mRNA level. CONCLUSIONS: The transition to isolated diastolic heart failure in hypertrophied hearts was associated with preserved gene expression of the renin-angiotensin system and 'overdrive' of gene expression of the ET system. BNP gene expression is likely to be activated by the progression of diastolic failure rather than by LV hypertrophy alone.

Analysis of Variance↗

Treatment of hypertrophic cardiomyopathy with coenzyme Q10.

Hypertrophic cardiomyopathy (HCM) is manifested by severe thickening of the left ventricle with significant diastolic dysfunction. Previous observations on the improvement in diastolic function and left ventricular wall thickness through the therapeutic administration of coenzyme Q10 (CoQ10) in patients with hypertensive heart disease prompted the investigation of its utility in HCM. Seven patients with HCM, six non-obstructive and one obstructive, were treated with an average of 200 mg/day of CoQ10 with mean treatment whole blood CoQ10 level of 2.9 micrograms/ml. Echocardiograms were obtained in all seven patients at baseline and again 3 or more months post-treatment. All patients noted improvement in symptoms of fatigue and dyspnea with no side effects noted. The mean interventricular septal thickness improved significantly from 1.51 +/- 0.17 cm to 1.14 +/- 0.13 cm, a 24% reduction (P < 0.002). The mean posterior wall thickness improved significantly from 1.37 +/- 0.13 cm to 1.01 +/- 0.15 cm, a 26% reduction (P < 0.005). Mitral valve inflow slope by pulsed wave Doppler (EF slope) showed a non-significant trend towards improvement, 1.55 +/- 0.49 m/sec2 to 2.58 +/- 1.18 m/sec2 (P < 0.08). The one patient with subaortic obstruction showed an improvement in resting pressure gradient after CoQ10 treatment (70 mmHg to 30 mmHg).

Aged↗

Bronchial responsiveness in patients on regular hemodialysis treatment of very long duration.

Several mechanisms (trapping of neutrophils, increased extravascular lung water, left ventricular hypertrophy, metastatic lung calcification, and iron deposition) may impair pulmonary function and alter bronchial responsiveness in patients on long-term regular dialysis treatment (RDT), but no studies have been published concerning patients on RDT for a very long time. To assess bronchial reactivity, a methacholine inhalation test was performed 2 to 24 hours after a dialysis session in 19 patients with RDT duration of almost 20 years (221 +/- 26 months) (group 1) and in 14 patients on RDT for a shorter time (24 +/- 22 months) (group 2); all patients had normal standard pulmonary function test results (group 1: forced vital capacity, 95% +/- 13% and forced expiratory volume in one second [FEV1]: 97% +/- 17%; group 2: forced vital capacity, 108% +/- 11% and FEV1, 108% +/- 9% of expected values). The methacholine provocation dose causing a 20% decrease in FEV1 was significantly lower than normal in seven (37%) group 1 patients and only in one (7%) group 2 patient; this difference was statistically significant (P = 0.049). There were no correlations between bronchial hyperresponsiveness and interdialysis weight gain, left ventricular hypertrophy, diastolic dysfunction expressed as the ratio between early diastolic filling and filling during atrial contraction, secondary hyperparathyroidism, and iron overload. Therefore, bronchial hyperresponsiveness is present in a substantial percentage of patients on RDT of very long duration, but the cause is unknown.

Adult↗

Angiotensin-converting enzyme inhibitors in heart failure: physicians' prescribing behavior.

BACKGROUND: Several studies document an underuse of angiotensin-converting enzyme inhibitors (ACEIs) in heart failure (HF) patients, despite their proven efficacy and good tolerability. Also, there is some evidence that the doses used in clinical practice are far lower than those used in clinical trials. METHODS AND RESULTS: To identify patterns of ACEI use in HF patients this study examined data collected on admission day regarding demographic, clinical, and medical care characteristics of 355 patients hospitalized because of decompensated HF who were treated with and without ACEIs. Additionally, measures of in-hospital outcome were compared among the two groups. Fifty-eight point six percent of patients were receiving ACEIs at admission and 80.6% were treated with ACEIs during hospitalization. The average ACEI does was low. No differences were observed in age and measures of severity of HF between ACEI-prescribed and nonprescribed patients. Patterns that could explain ACEI underuse included female sex, lower systolic blood pressure, worse renal function, left ventricular diastolic dysfunction, use of alternate drugs (eg, spironolactone), and overall less intense medical management. Patterns associated with the use of lower doses of ACEIs included older age, higher New York Heart Association functional class, and lower systolic blood pressure. In-hospital death rates were significantly higher for patients not treated with ACEIs. CONCLUSIONS: This study suggests that many patients eligible for ACEI treatment were deprived of the advantages of these drugs because of erroneous clinical strategies. Nevertheless, the patterns of ACEI use were similar to those reported by other studies. Clinical trials conducted to determine the risk/benefit ratio of ACEI use in patients with renal dysfunction and the utility of ACEIs in diastolic HF, as well as programs to educate care providers on proper use of ACEIs in HF patients, are strongly recommended.

Aged↗

Preimplantation echo Doppler evaluation of VVI versus DDD pacing.

UNLABELLED: This study was carried out to select before permanent pacemaker implantation patients with complete atrioventricular block (CHB) who would benefit best from DDD pacing, and to determine the optimal atrioventricular delay (AVD) for each of those patients. This was achieved with the aid of Doppler echocardiography. The effect of different AVDs on both the systolic and diastolic function of the normal and failing heart was also delineated in this study. METHODS: Thirty patients with CHB and normal sinoatrial function were selected, with no age or sex predilection. These patients were categorized into three equal groups: groups A, B, and C with normal left ventricular (LV) systolic and diastolic function, LV diastolic dysfunction, and LV systolic dysfunction, respectively. For each patient, systolic and diastolic function was calculated utilizing echo Doppler during CHB, temporary VDD pacing with different AVDs, and temporary VVI pacing with a rate matching that during VDD mode. Temporary VDD mode of pacing was performed utilizing a temporary bipolar ventricular lead for ventricular pacing and an esophageal lead for atrial sensing to trigger ventricular pacing. RESULTS: Qualitatively the most obvious change in the pattern of LV filling as AVD is increased in the three groups, is the earlier occurrence of active atrial filling A wave due to progressive approximation of the ECG P wave toward the previous QRS. As the AV interval is increased, the following changes occur: (a) A wave occurs progressively earlier with superimposition onto the early filling E wave resulting in a progressive increase in its velocity (VA), its FVI, and its percent atrial contribution (%AC); (b) the three times diastolic filling time (DFT), mitral valve opening to Q wave (MVO-Q), and closure (Q-MVC) progressively shorten; (c) since DFT decreases, less passive filling occurs early during diastole, thus E.FVI decrease with longer AV intervals; (d) the ratios VE/VA and FVI E/A decrease subsequently to the previous described changes. Compared to CHB, percent ejection fraction (% EF) was not significantly changed during VVI pacing. Percent EF increased significantly during VDD in comparison to VVI pacing modes. Percent EF was highest at optimal AVD and decreased as this AVD increased or decreased. The cardiac output (CO) increment during VDD in comparison to VVI pacing modes differed much among the three groups. In group A, a 10.29% increase in CO was seen when comparing VDD pacing (with optimal AVD) with that of VII one; in group B, this increment was much greater and reached 29.48%; in group C it reached 23.68%.(ABSTRACT TRUNCATED AT 400 WORDS)

Blood Flow Velocity↗

Congestive heart failure.

Congestive heart failure (CHF) is a condition that is increasing in incidence and is associated with significant morbidity and mortality rates. The main abnormality that underlies CHF is depressed myocardial function. The resulting decrease in cardiac output activates several peripheral compensatory mechanisms, which may further impair ventricular function and worsen the prognosis. Although systolic dysfunction is the traditional descriptor of CHF, diastolic dysfunction is increasingly recognized as a distinct entity. In prescribing therapy the predominant type of ventricular dysfunction and the peripheral components of the heart failure should be identified. The ultimate aim is to alleviate symptoms, minimize complications and prolong survival. Recent data from two multicentre trials have suggested that vasodilators can achieve these goals. Trials are under way to assess the impact of early vasodilator therapy on CHF.

Calcium Channel Blockers↗

Assessment of ventricular diastolic function.

A large number of patients suspected of having congestive heart failure have normal left ventricular systolic function and may, therefore, have primary diastolic heart failure. This diagnosis, however, should not be made unless there is also objective evidence of diastolic dysfunction, ie, signs of abnormal left ventricular relaxation and/or diastolic distensibility. The most useful noninvasive diagnostic approaches are the measurement of transmitral and pulmonary venous flow velocities by pulsed wave Doppler, and mitral annulus velocities by tissue Doppler echocardiography. In some patients, the assessment of intraventricular flow propagation by colour M-mode Doppler echocardiography provides additional information. Diastolic heart failure is most often due to coronary artery disease and/or hypertension; therefore, other noninvasive or invasive tests are needed to define the etiology of myocardial dysfunction. However, in the few patients who have constrictive pericarditis, the Doppler echocardiographic assessment of diastolic filling provides the most important clues to the etiology of the disease. Doppler echocardiographic assessment of left ventricular filling may also be used to obtain semiquantitative estimates of left ventricular diastolic pressure. Furthermore, left ventricular filling patterns, in particular, the deceleration time of early transmitral filling, are powerful predictors of patient prognosis. It is probably not cost effective to perform a comprehensive assessment of diastolic filling in every patient undergoing an echocardiographic examination. However, in selected patients, the assessment of diastolic filling provides information that is important for patient management.

Diastole↗

Cardiovascular hemodynamic effects of correction of anemia of chronic renal failure with recombinant-human erythropoietin.

The results of 8 to 12 weeks of treatment of the anemia of uremia with rHuEPO in patients with chronic renal failure and uremia are: a sustained increased hematocrit; increased RBC mass, and subsequent increased MAP; and increased TPRI. The observed trends of decreased LVEF, and echo Doppler evidence of a trend toward LV systolic and diastolic dysfunction, although not individually statistically significant, represent 3 separate evaluation techniques coupled with hypertension and TPRI increase during administration of rHuEPO to increase the hematocrit and packed red blood cell volume in patients with chronic renal failure and anemia. Increased TPRI and hypertension associated with correction of uremic anemia vasodilation and the increased blood viscosity have been noted in earlier investigations with transfusions. The hypertension and elevated TPRI demonstrated during rHuEPO therapy in patients with progressive chronic renal failure associated with increased hematocrit, and the trends toward systolic and diastolic cardiac dysfunction are noted herein. These changes were associated with the combined increase of packed RBC mass and plasma volume in this study. The natural progressive course of worsening of renal function exhibited by these patients could have limited their ability to regulate plasma volume, making them vulnerable to volume-dependent hypertension and a significant preload adding to potential cardiac dysfunction in addition to the increased TPRI.

Anemia↗