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Probucol attenuates left ventricular dysfunction and remodeling in tachycardia-induced heart failure: roles of oxidative stress and inflammation.

BACKGROUND: Oxidative stress and inflammation are potentially involved in the pathogenesis of heart failure (HF). We examined whether antioxidant and antiinflammatory treatment with probucol decreases myocardial oxidative stress and inflammation and attenuates the progression of left ventricular (LV) dysfunction and remodeling (dilatation) in tachycardia-induced HF. METHODS AND RESULTS: We studied 3 groups of dogs: a sham-operated control group and 2 other groups that underwent ventricular pacing at 240 bpm with and without probucol treatment (100 mg/kg IP per week) for 4 weeks. Dogs that underwent ventricular pacing for 4 weeks developed signs of HF, such as a reduction in the LV ejection fraction and increases in the LV end-diastolic dimension and LV end-diastolic pressure. Myocardial oxidative stress, as measured by electron spin resonance spectroscopy with 4-hydroxy-2,2,6,6,-tetramethyl-piperidine-N-oxyl (hydroxy-TEMPO), was significantly increased. There was an increase in myocardial monocyte infiltration, monocyte chemoattractant protein-1 expression, and renin-angiotensin system and matrix metalloproteinase activity. Probucol treatment prevented increases in oxidative stress, inflammation, and matrix metalloproteinase activity and attenuated LV dysfunction and remodeling. CONCLUSIONS: Probucol attenuated LV dysfunction and remodeling, possibly through its antioxidant and/or antiinflammatory effects in ventricular pacing-induced HF. These data suggest that inflammatory disorders, which cause an abnormal interaction between failing myocardium and activated monocytes, have an important role in the progression of HF.

Animals↗

Revascularization for patients with severe coronary artery disease and left ventricular dysfunction.

Heart failure is becoming increasingly prevalent, and currently coronary artery disease (CAD) is the primary cause of left ventricular (LV) systolic dysfunction. A potential therapeutic option for patients with severe CAD and LV dysfunction is a strategy of revascularization. In this review, we summarize the available literature regarding revascularization for these patients. The literature suggests that patients with severe CAD and LV dysfunction may benefit from revascularization and those patients with viable myocardium may derive the most benefit.

Angioplasty, Balloon, Coronary↗

Association of right ventricular dysfunction and Cheyne-Stokes respiration in patients with chronic heart failure.

Cheyne-Stokes respiration (CSR) is present in up to 40% of patients with congestive heart failure (CHF) and is an independent risk factor for increased overall mortality. We examined whether CSR is associated with right ventricular (RV) dysfunction in CHF patients. Parameters of RV function were assessed by two-dimensional echocardiography and tissue velocity imaging in 42 patients (aged 23-75 years) with a left ventricular (LV) ejection fraction below 40%. Respiratory polygraphy revealed CSR with an central apnea-hypopnea index (CAHI) >10 h-1 in 13 of the 42 patients (31%). Demographic characteristics did not differ among the patient groups. The velocity of the tricuspid annular systolic motion (TASM), a parameter reflecting systolic RV function, was significantly reduced in CHF patients with CSR (10.5 +/- 2.3 cm s-1) compared with those without CSR (15.0 +/- 5.1 cm s-1, P = 0.004), and was inversely associated with the CAHI (y = 15.2-0.2x; r = 0.46, P = 0.003). The RV dimensions were significantly increased and the fractional RV area changes significantly reduced in CHF patients with CSR (33 +/- 17 versus 48 +/- 20%; P = 0.04). Doppler parameters of pulmonary artery flow indicate higher pulmonary artery pressures in CSR patients compared with patients without CSR, which is also reflected by an increased RV free-wall thickness in CSR patients (6.5 +/- 1.1 vs. 5.3 +/- 1.3 mm; P = 0.05). Parameters of systolic LV function, forced expiratory volume in 1 s (FEV1), and PaO2 and PaCO2 were not different among patients with or without CSR. In conclusion, CSR is associated with depressed systolic RV function and increased RV dimensions in CHF patients. Future studies will show whether optimized treatment of CSR will improve RV function.

Adult↗

Previously known and newly diagnosed atrial fibrillation: a major risk indicator after a myocardial infarction complicated by heart failure or left ventricular dysfunction.

AIMS: To characterize the relationship between known and newly diagnosed atrial fibrillation (AF) and the risk of death and major cardiovascular (CV) events in patients with acute myocardial infarction (MI) complicated by heart failure (HF) and/or left ventricular systolic dysfunction (LVSD). METHODS: The VALIANT trial enrolled 14,703 individuals with acute MI complicated by HF and/or LVSD. AF was assessed at presentation and at randomization (median 4.9 days after symptom onset). Primary outcomes were risk of death and major CV events 3 years following acute MI. RESULTS: A total of 1812 with current AF (AF between presentation and randomization), 339 patients with prior AF (history of AF without current AF), and 12,509 without AF were enrolled. Patients with AF were older; had more prior HF, angina, and MI, and received beta-blockers and thrombolytics less often than those without AF. Three-year mortality estimates were 20% in those without AF, 37% with current AF, and 38% with prior AF. Compared with patients without AF, the multivariable adjusted HR of death was 1.25 (1.03-1.52; p=0.03) for prior AF and 1.32 (1.20-1.45; p<0.0001) for current AF. HR for major CV events was 1.15 (0.98-1.35; p=0.08) and 1.21 (1.12-1.31; p<0.0001). CONCLUSION: AF is associated with greater long-term mortality and adverse CV events with acute MI complicated by HF or LVSD.

Acute Disease↗

Growth hormone-releasing peptide can improve left ventricular dysfunction and attenuate dilation in dilated cardiomyopathic hamsters.

OBJECTIVE: The mammalian heart contains specific growth hormone-releasing peptide (GHRP) binding sites whose physiological significance is unknown. We sought to compare the effects of GHRP and GH on progressive left ventricular (LV) dysfunction in the TO-2 hamster model of dilated cardiomyopathy. METHODS: TO-2 hamsters (8 weeks old) were injected with GHRP-6 (100 microg/kg day), GH (2 mg/kg day), or saline for 4 weeks; F1B hamsters served as controls. LV functional and structural changes were evaluated by echocardiography and pathology. RESULTS: The increase in body weight of GH-treated TO-2 hamsters was greater than that of animals in the other two groups. Plasma GH and insulin-like growth factor-1 (IGF-1) concentrations were not increased by GHRP-6. LV fractional shortening (LVFS) decreased from 42.0+/-2.6% to 25.4+/-1.8% and the LV end-diastolic dimension (LVDd) increased from 4.0+/-0.1 to 5.0+/-0.1 mm in untreated TO-2 hamsters between 8 and 12 weeks. LVFS was substantially improved by treatment with GHRP-6 (33.4+/-2.0%) or GH (32.0+/-2.1%). The LVDd was significantly smaller in animals treated with GHRP-6 than in those treated with GH. The cross-sectional LV myocyte area and the amount of atrial natriuretic peptide mRNA in the LV were increased by GH but not by GHRP-6. Treatment woth GH at a lower dose (0.2 mg/(kg day)) exerted minimal cardiac and systematic growth effects without improving LV function. CONCLUSION: GHRP can ameliorate the development of progressive LV dysfunction independently of the GH-IGF-1 axis, suggesting a potential new approach to the heart failure.

Animals↗

Comparison of methods of fractional area change for detection of regional left ventricular dysfunction.

Three methods for assessment of fractional area change (FAC) and conventional versus cross-sectional segmentation were compared under conditions known to occur frequently during stress echocardiography. Quantitative analysis of 80 echocardiograms obtained from healthy subjects, patients with left ventricular (LV) dysfunction and after coronary artery bypass grafting included segmental and cross-sectional FACs by the centroid method with fixed and floating reference and a method with floating external reference. All segmental and cross-sectional FACs were equally sensitive to LV dysfunction, and segmental FACs failed to accurately predict the location of coronary lesions. The centroid method with floating reference and cross-sectional FACs were the least affected by surgery induced intrathoracic heart motion. In moderate to severe LV dysfunction FAC by the centroid method with floating reference and cross sections were rarely within normal limits. Cross-sectional FACs may prove to be useful in stress echocardiography. For viability studies segmental FAC by fixed reference appears to be the method of choice.

Adult↗

Prediction of functional recovery after revascularization in patients with chronic ischaemic left ventricular dysfunction: head-to-head comparison between 99mTc-sestamibi/18F-FDG DISA SPECT and 13N-ammonia/ 18F-FDG PET.

PURPOSE: (18)F-FDG PET is an important modality for myocardial viability assessment in patients with left ventricular (LV) dysfunction. Dual-isotope simultaneous acquisition (DISA) SPECT may be an alternative to PET. The aim of this study was to compare the diagnostic performance of PET and DISA SPECT for the prediction of improvement in regional and global LV function as well as LV reverse remodelling after revascularization. METHODS: Patients (n=47) with chronic coronary artery disease and LV dysfunction underwent DISA SPECT (with (99m)Tc-sestamibi and (18)F-FDG) and PET (with (13)N-ammonia and (18)F-FDG) on the same day to assess viability. All patients underwent revascularization and recovery of function was derived from serial magnetic resonance imaging studies. RESULTS: Of 264 revascularized, dysfunctional segments, 143 (54%) improved in function. For prediction of improvement in regional LV function, PET and DISA SPECT had similar sensitivity (90% versus 89%, NS) and specificity (86% versus 86%, NS). For prediction of improvement in global LV function, sensitivity was 83% for DISA SPECT and 86% for PET (p=NS), whereas both modalities had a specificity of 100%. Finally, sensitivity and specificity for the prediction of LV reverse remodelling were also similar for DISA SPECT and PET. CONCLUSION: In patients undergoing revascularization, DISA SPECT and PET predict the improvement in regional and global LV function and LV remodelling equally well post revascularization.

Aged↗

[Cardiac tomography with 99mTc-tetrofosmin after nitrate administration in patients with ischemic cardiopathy and left ventricular dysfunction].

PURPOSE: To investigate the role of technetium-99m (99mTc) tetrofosmin single-photon emission Computed Tomography (SPECT) associated with nitrate administration in the detection of hypoperfused but still viable myocardium in patients with chronic coronary artery disease and left ventricular (LV) dysfunction. MATERIAL AND METHODS: Twenty-two patients (mean age 54 +/- 11 years) with coronary artery disease, previous myocardial infarction and LV dysfunction (LV ejection fraction 38 +/- 13%) were examined. On different days all patients underwent 99mTc tetrofosmin (740 MBq) SPECT under control conditions at rest and after sublingual nitroglycerin administration (10 mg). Regional tetrofosmin activity was quantitatively measured in 22 myocardial segments per patient. In each segment, tracer uptake was expressed as a percentage of the region with the peak activity. RESULTS: Under control conditions, 267 myocardial segments (55%) showed normal tetrofosmin uptake (> 70% of peak activity), 107 segments (22%) showed a moderate reduction (51-70%) and 110 segments (23%) a severe reduction (< or = 50%) in tracer uptake. Among the 110 segments with a severe reduction in tetrofosmin uptake, 20 (18%) showed increased tracer uptake > or = 10% of after nitrate administration (from 44 +/- 5% to 58 +/- 3%, p < 0.0001). The remaining 90 (82%) segments with a severe reduction in tetrofosmin uptake did not show any change after nitroglycerin administration (from 38 +/- 9% to 39 +/- 8%, p = ns). CONCLUSIONS: In patients with chronic coronary artery disease and LV dysfunction, tetrofosmin cardiac SPECT associated with sublingual nitrate administration allows the detection of severely hypoperfused but still viable myocardium.

Adult↗

Strain rate dobutamine echocardiography for prediction of recovery after revascularization in patients with ischemic left ventricular dysfunction.

BACKGROUND: The purpose of the present study was to assess the accuracy of quantitative segmental analysis by strain rate imaging (SRI) technique during dobutamine test for detecting myocardial recovery after revascularization in patients with chronic ischemic regional left ventricular (LV) dysfunction and compare results with those of 2-dimensional echocardiography (2D) and tissue Doppler imaging (TDI) as well as rest-4 hours-24 hours redistribution thallium SPECT (Tl SPECT). METHODS AND RESULTS: Forty-one patients with chronic ischemic regional LV dysfunction (EF 29 +/- 8%) underwent dobutamine 2D/TDI/SRI and Tl SPECT before and after myocardial revascularization. The sensitivity, specificity, and accuracy for the recovery of regional LV function were 73%, 81%, and 77% for dobutamine 2D; 77%, 82%, and 80% for dobutamine TDI; 86%, 88%, and 85% for dobutamine SRI; and 94%, 76%, and 84% for Tl tomography. The area under the ROC curve (AUC), which reflects the overall performance for the prediction of recovery, was 0.79 for systolic-SR, 0.81 for Tl SPECT, 0.83 for postsystolic strain, and 0.87 for isovolumic-SR. If both systolic and postsystolic SRI indexes were combined with Tl SPECT, the AUC was improved to 0.94. CONCLUSIONS: Dobutamine SRI is more accurate than TDI in identifying hibernating myocardium. Systo-diastolic values obtained using dobutamine SRI echocardiography and values derived from nuclear perfusion techniques may be complementary in assessing myocardial viability.

Adult↗

Chronic administration of ghrelin improves left ventricular dysfunction and attenuates development of cardiac cachexia in rats with heart failure.

BACKGROUND: Ghrelin is a novel growth hormone (GH)-releasing peptide that may also induce vasodilation and stimulate feeding through GH-independent mechanisms. We investigated whether ghrelin improves left ventricular (LV) dysfunction and attenuates cardiac cachexia in rats with chronic heart failure (CHF). METHODS AND RESULTS: Ligation of the left coronary artery or sham operation was performed; 4 weeks after surgery, rat ghrelin (100 microg/kg SC BID) or saline was administered for 3 weeks. Echocardiography and cardiac catheterization were performed. Serum GH and insulin-like growth factor-1 were significantly higher in both CHF and sham rats treated with ghrelin than in those given placebo (P<0.05 for both). CHF rats given placebo showed an impaired increase in body weight compared with sham rats given placebo (P<0.05). CHF rats treated with ghrelin, however, showed a significantly greater increase in body weight than those given placebo (+10% versus +3%, P<0.05). They showed significantly higher cardiac output (315+/-49 versus 266+/-31 mL. min(-1). kg(-1), P<0.05) and LV dP/dt(max) (5738+/-908 versus 4363+/-973 mm Hg/s, P<0.05) than CHF rats given placebo. Ghrelin increased diastolic thickness of the noninfarcted posterior wall, inhibited LV enlargement, and increased LV fractional shortening in CHF rats (from 15+/-3% to 19+/-3%, P<0.05). CONCLUSIONS: Chronic subcutaneous administration of ghrelin improved LV dysfunction and attenuated the development of LV remodeling and cardiac cachexia in rats with CHF.

Animals↗

Predictors of cardiac survival after percutaneous transluminal coronary angioplasty in patients with severe left ventricular dysfunction.

To assess the outcome of percutaneous transluminal coronary angioplasty (PTCA) in patients with severe left ventricular (LV) dysfunction and to determine the predictors of mortality, 73 patients with LV ejection fraction less than or equal to 40% who underwent initial PTCA were analyzed. The majority of patients had prior (greater than 1 week) myocardial infarction (62 patients, 85%). Congestive heart failure and unstable angina were present in 24 (45%) and 49 (67%) patients, respectively. Multivessel coronary artery disease was present in 60 (83%). The LV ejection fraction ranged from 14 to 40% (mean 34%). Intraaortic balloon pump (15%) and percutaneous cardiopulmonary bypass support (4%) was used infrequently. Angiographic success was obtained in 109 of 128 lesions (85%) attempted. Complete revascularization was obtained in 16 of 60 patients with clinical success. Procedure-related mortality was 5% (4 patients). All patients were followed from greater than or equal to 6 to less than or equal to 71 months (average 26). The estimated survival was 79 +/- 5%, 74 +/- 6%, 66 +/- 7% and 57 +/- 8% at 1, 2, 3 and 4 years, respectively. A Cox regression analysis revealed that the presence of congestive heart failure, a lower LV ejection fraction and a higher myocardial jeopardy score for contractile myocardium were independent predictors of survival after PTCA in patients with LV dysfunction. In conclusion, a high-risk subset can be identified among patients with severe LV dysfunction who undergo PTCA.

Angioplasty, Balloon, Coronary↗

Preoperative pulmonary hypertension is associated with postoperative left ventricular dysfunction in chronic organic mitral regurgitation: an echocardiographic and hemodynamic study.

BACKGROUND: Some degree of pulmonary hypertension (PHTN) is common in patients with chronic mitral regurgitation. The aim of this study was to determine whether preoperative PHTN is associated with postoperative left ventricular (LV) dysfunction. METHODS: The study included 79 patients with chronic organic mitral regurgitation. Preoperative and postoperative LV function was assessed by echocardiography. Preoperative and postoperative hemodynamics were evaluated by a pulmonary artery catheter. RESULTS: Pulmonary artery systolic pressure decreased postoperatively (pre 49 +/- 14 vs. post 36 +/- 11 mm Hg, P < .01). Postoperative LV ejection fraction was significantly reduced in patients with preoperative PHTN (pre 61 +/- 11% vs post 49 +/- 12%, P < .01). A stepwise multivariate regression analysis showed that preoperative pulmonary artery systolic pressure and LV end-systolic dimension were independent predictors of postoperative LV ejection fraction (r = -0.53, P < .001, and r = -0.34, P < .05, respectively). CONCLUSION: Preoperative PHTN is associated with postoperative LV dysfunction in patients with chronic organic mitral regurgitation undergoing mitral valve operation.

Chronic Disease↗

Quantitative analysis of myocardial glucose utilization in patients with left ventricular dysfunction by means of 18F-FDG dynamic positron tomography and three-compartment analysis.

PURPOSE: Myocardial glucose utilization (MGU) is altered in various heart diseases. The aim of this study was to quantitatively assess regional myocardial glucose utilization in patients with left ventricular (LV) dysfunction by dynamic( 18)F-fluorodeoxyglucose positron emission tomography (FDG PET). METHODS: A total of 18 subjects were studied, including ten with LV dysfunction (seven with idiopathic dilated cardiomyopathy and three with aortic regurgitation; NYHA II in 8 and III in 2) and eight healthy normal volunteers. Patients with diabetes mellitus were excluded. A dynamic PET study was performed for 40 min following the injection of 370 MBq of FDG after 50-g glucose loading. On the basis of a three-compartment model, MGU, K1, k2, and k3 were computed on a pixel by pixel basis to generate LV myocardial parametric maps. FDG standardized uptake value (SUV) was also calculated using static images obtained 40 min after FDG injection. These metabolic values were compared with myocardial flow distribution (%Flow), LVEF, LV volumes, and LV wall thickening (WT) determined by gated myocardial single-photon emission computed tomography using QGS software in eight myocardial segments. RESULTS: MGU correlated positively with LV volumes and negatively with LVEF. K(1) was significantly higher in the segments of the patients than in those of the normal volunteers (0.082+/-0.055 vs 0.041+/-0.017 ml min(-1) g(-1), p<0.05), although there was no difference in MGU between the groups. On the other hand, SUV, k2, and k3 did not differ significantly between the groups. Among the patients, the K1 values were significantly higher in the areas with impaired WT (%WT<17%) (0.109+/-0.063 vs 0.069+/-0.062 ml min(-1) g(-1), p<0.05) and in the areas with flow reduction (%Flow<71%) (0.112+/-0.076 vs 0.071+/-0.046 ml min(-1) g(-1), p<0.05). CONCLUSION: These results indicate that glucose utilization was preserved in the patients with LV dysfunction, mainly due to an increase in glucose transport, particularly in the regions with severely impaired LV function. Thus, the quantitative assessment of myocardial glucose utilization by FDG dynamic PET may provide useful information for assessing the regional myocardial metabolic status in patients with LV dysfunction.

Aged↗

[Congestive heart failure in the aged. Causes and mechanisms of left ventricular dysfunction].

UNLABELLED: AGING PROCESS: Aging can be defined as an association of senescence and disease states. Aging induces changes in adaptive processes, modifying heart failure pathophysiology. MECHANISMS: In a population over 75, half of the patients with congestive heart failure have normal left ventricular systolic function. Heart failure in these patients results from ventricular diastolic dysfunction. Hypertension and coronary heart disease are the main causes of heart failure. THERAPEUTIC IMPLICATIONS: Identifying the etiology and the underlying mechanism (systolic or diastolic) are essential steps guiding further management.

Aged↗

Prevalence of heart failure and systolic ventricular dysfunction in older Australians: the Canberra Heart Study.

OBJECTIVE: To estimate the prevalence of heart failure (HF) and left ventricular (LV) systolic dysfunction in a population-based sample of older Australians. DESIGN, SETTING AND PARTICIPANTS: A cross-sectional survey of 2000 randomly selected residents of Canberra, aged 60-86 years, conducted between February 2002 and June 2003. Participants were assessed by history, physical examination by a cardiologist, and echocardiography. MAIN OUTCOME MEASURES: Age- and sex-specific prevalence rates of clinical HF and LV systolic dysfunction (defined as LV ejection fraction < or = 50%). RESULTS: Of 1846 people eligible for our study, 1388 (75%) agreed to participate and 1275 completed all investigations (mean age, 69.4 years; 50% men). In the study sample, 72 subjects (5.6%; 95% CI, 4.4%-7.1%) had clinical HF that had been previously diagnosed and was confirmed by our assessment. A further 0.6% (95% CI, 0.3%-1.2%) had undiagnosed clinical HF (ie, evidence of structural heart disease and symptoms/signs of cardiac insufficiency without a previous diagnosis of clinical HF). Thus, the overall prevalence of clinical HF in the sample was 6.3% (95% CI, 5.0%-7.7%). Clinical HF increased in prevalence with advancing age (a 4.4-fold increase from the 60-64-years age group to the 80-86-years age group; P < 0.0001). Of the 75 subjects (5.9%; 95% CI, 4.7%-7.3%) with LV systolic dysfunction, 44 (59%) were in the preclinical stage of disease. CONCLUSION: Diagnosed HF cases represent the "tip of the iceberg" for the national burden of HF and LV systolic dysfunction. Clinically identifiable HF cases can remain undiagnosed, and the majority of people with LV systolic dysfunction are in a preclinical stage of the disease.

Age Factors↗

Dobutamine echocardiography in patients with aortic stenosis and left ventricular dysfunction: predicting outcome as a function of management strategy.

STUDY OBJECTIVE: To prospectively address the question whether the assessment of valvular hemodynamics and myocardial function during low-dose dobutamine infusion can guide decision making in patients with aortic stenosis and left ventricular (LV) dysfunction. PATIENTS AND MEASUREMENTS: Twenty-four patients with aortic stenosis and LV dysfunction (mean ejection fraction, 28%; New York Heart Association class, II to IV) were studied by dobutamine echocardiography assessing mean pressure gradient, aortic valve area, and aortic valve resistance. Patients were prospectively divided into severe and nonsevere aortic stenosis groups according to the response of the valve area to the augmentation of systolic flow. The clinical decision was considered to be concordant with the results of dobutamine echocardiography, when patients with severe aortic stenosis and preserved contractile function were referred by a specialist for aortic valve replacement and when patients with nonsevere aortic stenosis were not. Patients were observed for up to 3 years. RESULTS: All eight patients with severe aortic stenosis who were referred for surgery survived and had good cardiovascular outcomes, and six of eight patients who were not initially referred for surgery had poor outcomes, including heart failure and sudden cardiac death. The eight patients with nonsevere aortic stenosis did comparatively well without valve replacement. Cardiac death or pulmonary edema occurred in 4 of 16 patients (25%) when the clinical decision was concordant with the results of the dobutamine echocardiogram and occurred in 6 of 8 patients (75%) when the clinical decision was discordant (p = 0.019 [chi(2) test]). CONCLUSION: Patients with aortic stenosis, LV dysfunction, and relatively low gradients have better outcomes when management decisions are based on the results of dobutamine echocardiograms. Those patients identified as having severe aortic stenosis and preserved contractile reserve by dobutamine echocardiography should undergo surgery, while patients identified as having nonsevere aortic stenosis can be managed conservatively.

Aged↗