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PubMed1996

The effect of carvedilol on morbidity and mortality in patients with chronic heart failure. U.S. Carvedilol Heart Failure Study Group.

BACKGROUND: Controlled clinical trials have shown that beta-blockers can produce hemodynamic and symptomatic improvement in chronic heart failure, but the effect of these drugs on survival has not been determined. METHODS: We enrolled 1094 patients with chronic heart failure in a double-blind, placebo-controlled, stratified program, in which patients were assigned to one of the four treatment protocols on the basis of their exercise capacity. Within each of the four protocols patients with mild, moderate, or severe heart failure with left ventricular ejection fractions < or = 0.35 were randomly assigned to receive either placebo (n = 398) or the beta-blocker carvedilol (n = 696); background therapy with digoxin, diuretics, and an angiotensin-converting-enzyme inhibitor remained constant. Patient were observed for the occurrence death or hospitalization for cardiovascular reasons during the following 6 months, after the beginning (12 months for the group with mild heart failure). RESULTS: The overall mortality rate was 7.8 percent in the placebo group and 3.2 percent in the carvedilol group; the reduction in risk attributable to carvedilol was 65 percent (95 percent confidence interval, 39 to 80 percent; P < 0.001). This finding led the Data and Safety Monitoring Board to recommend termination of the study before its scheduled completion. In addition, as compared with placebo, carvedilol therapy was accompanied by a 27 percent reduction in the risk of hospitalization for cardiovascular causes (19.6 percent vs. 14.1 percent, P = 0.036), as well as a 38 percent reduction in the combined risk of hospitalization or death (24.6 percent vs, 15.8 percent, P < 0.001). Worsening heart failure as an adverse reaction during treatment was less frequent in the carvedilol than in the placebo group. CONCLUSIONS: Carvedilol reduces the risk or death as well as the risk of hospitalization for cardiovascular causes in patients with heart failure who are receiving treatment with digoxin, diuretics, and an angiotensin-converting-enzyme inhibitor.

Adrenergic alpha-Antagonists↗
PubMed2002

Vasopeptidase inhibitor reduces inhospital costs for patients with congestive heart failure: results from the IMPRESS trial. Inhibition of Metallo Protease by BMS-186716 in a Randomized Exercise and Symptoms Study in Subjects With Heart Failure.

BACKGROUND: The Inhibition of Metallo Protease by BMS-186716 in a Randomized Exercise and Symptoms Study in Subjects With Heart Failure (IMPRESS) clinical trial randomized patients with congestive heart failure to a daily regimen of either omapatrilat or lisinopril. At 24 weeks, patients randomized to omapatrilat had a significant reduction in the combined end point of death, hospitalization, or discontinuation of study drug for worsening heart failure when compared with patients randomized to lisinopril. They also had significantly fewer serious cardiac adverse events. OBJECTIVE: This study sought to determine the economic consequences of the lower event rates of patients who were given omapatrilat. METHODS: Economic outcomes (major hospitalizations and their associated medical costs) were compared between treatment groups and assessed by use of the societal perspective. Hospitalization information was obtained from the IMPRESS trial's standardized case report and serious adverse event forms. Hospital costs were evaluated by means of assigning each hospital admission a diagnosis-related group and an average cost for physician and hospital services. Emergency department visits were included only when they were made for worsening heart failure and were assigned costs equivalent to the average hospital and physician Medicare reimbursement for these visits in Duke University Medical Center's heart failure program. Drug costs were not assessed. RESULTS: Although the typical patient in both treatment groups was event-free, there was a trend toward a greater number of hospitalizations in the patients given lisinopril than in the patients given omapatrilat (P =.07). Differences in the distribution of cardiac hospitalizations between patients given lisinopril and patients given omapatrilat were significant (P =.03). There was a trend toward lower medical costs at 24 weeks in patients given omapatrilat versus patients given lisinopril ($1930 vs $2002, P =.09). Considering only cardiac medical costs, this trend toward reduced medical costs was significant ($1240 vs $1442, P =.03). CONCLUSIONS: At 24 weeks, patients with heart failure treated with omapatrilat had fewer hospitalizations and lower medical costs than patients treated with lisinopril. However, drug treatment costs were not available for this analysis.

Cardiotonic Agents↗
PubMedDate not supplied

Pharmacotherapy in congestive heart failure: diuretic resistance and strategies to overcome resistance in patients with congestive heart failure.

Congestive heart failure is a complex clinical hemodynamic disorder characterized by chronic and progressive pump failure and fluid accumulation. Although the overall impact of diuretic therapy on congestive heart failure mortality remains unknown, diuretics remain a vital component of symptomatic congestive heart failure management. Over time, sodium and water excretion are equalized before adequate fluid elimination occurs. This phenomenon is thought to occur in one out of three patients with congestive heart failure on diuretic therapy and is termed diuretic resistance. In congestive heart failure, both pharmacokinetic and pharmacodynamic alterations are thought to be responsible for diuretic resistance. Due to disease chronicity, symptomatic management is vital to improved quality of life and enhancing diuretic response is therefore pivotal.

Diuretics↗
PubMed2003

Optimal management of outpatients with heart failure using advanced practice nurses in a hospital-based heart failure center.

PURPOSE: To examine the benefits of an advanced practice nurse (APN) driven, hospital-based heart failure center. DATA SOURCES: Selected multidisciplinary studies, review articles, Heart Failure Society of America practice guidelines, and American College of Cardiology/American Heart Association clinical practice guidelines. CONCLUSIONS: APN specialists in this hospital-based heart failure center provide heart failure patients with high quality multidisciplinary health care in a single environment, which leads to optimal outcomes. Patients experience positive outcomes as evidenced by spared hospitalizations, improved scores on the Minnesota Living With Heart Failure Survey, and the 6-min walk. IMPLICATIONS FOR PRACTICE: APNs with prescriptive authority can effectively direct heart failure care for outpatients by utilizing multidisciplinary resources of the hospital. Treatment strategies include titrating medication, frequent symptom monitoring, tracking medication and dietary compliance, telemonitoring, and providing aggressive multidisciplinary education. This approach is highly effective for reducing hospital readmissions as well as for improving quality of life and functional status for outpatients with left ventricular systolic dysfunction.

Clinical Competence↗
PubMed1998

Elevated levels of 8-iso-prostaglandin F2alpha in pericardial fluid of patients with heart failure: a potential role for in vivo oxidant stress in ventricular dilatation and progression to heart failure.

BACKGROUND: It has been suggested that oxidant stress may play a role in the pathophysiology of heart failure. However, no definitive information is available because most previous approaches used to measure oxidant stress are nonspecific, inaccurate, and unreliable. METHODS AND RESULTS: To evaluate oxidant stress in the heart, we measured pericardial fluid levels of 8-iso-prostaglandin F2alpha (8-iso-PGF2alpha), a specific and quantitative marker of oxidant stress in vivo, in a series of 51 consecutive patients with ischemic and/or valvular heart disease referred for cardiac surgery. Pericardial levels of 8-iso-PGF2alpha were correlated with the functional severity of heart failure (NYHA classification) and with echocardiographic indices of ventricular dilatation measured by independent physicians. Pericardial levels of 8-iso-PGF2alpha were significantly increased in patients with symptomatic heart failure compared with asymptomatic patients and gradually increased with the functional severity of heart failure (P=.0003). In addition, pericardial levels of 8-iso-PGF2alpha were significantly correlated with left ventricular end-diastolic and end-systolic diameters (P=.008 and .026, respectively). CONCLUSIONS: Pericardial levels of 8-iso-PGF2alpha increase with the functional severity of heart failure and are associated with ventricular dilatation. These data suggest an important role for in vivo oxidant stress on ventricular remodeling and the progression to heart failure.

Adult↗
PubMed2006

Hemoglobin level, chronic kidney disease, and the risks of death and hospitalization in adults with chronic heart failure: the Anemia in Chronic Heart Failure: Outcomes and Resource Utilization (ANCHOR) Study.

BACKGROUND: Previous studies have associated reduced hemoglobin levels with increased adverse events in heart failure. It is unclear, however, whether this relation is explained by underlying kidney disease, treatment differences, or associated comorbidity. METHODS AND RESULTS: We examined the associations between hemoglobin level, kidney function, and risks of death and hospitalization in persons with chronic heart failure between 1996 and 2002 within a large, integrated, healthcare delivery system in northern California. Longitudinal outpatient hemoglobin and creatinine levels and clinical and treatment characteristics were obtained from health plan records. Glomerular filtration rate (GFR; mL.min(-1).1.73 m(-2)) was estimated from the Modification of Diet in Renal Disease equation. Mortality data were obtained from state death files; heart failure admissions were identified by primary discharge diagnoses. Among 59,772 adults with heart failure, the mean age was 72 years and 46% were women. Compared with that for hemoglobin levels of 13.0 to 13.9 g/dL, the multivariable-adjusted risk of death increased with lower hemoglobin levels: an adjusted hazard ratio (HR) of 1.16 and 95% confidence interval (CI) of 1.11 to 1.21 for hemoglobin levels of 12.0 to 12.9 g/dL; HR, 1.50 and 95% CI, 1.44 to 1.57 for 11.0 to 11.9 g/dL; HR, 1.89 and 95% CI, 1.80 to 1.98 for 10.0 to 10.9; HR, 2.31 and 95% CI, 2.18 to 2.45 for 9.0 to 9.9; and HR, 3.48 and 95% CI, 3.25 to 3.73 for <9.0 g/dL. Hemoglobin levels > or = 17.0 g/dL were associated with an increased risk of death (adjusted HR, 1.42; 95% CI, 1.24 to 1.63). Compared with those with a GFR > or = 60 mL . min(-1).1.73 m(-2), persons with a GFR <45 mL.min(-1).1.73 m(-2) had an increased mortality risk: adjusted HR, 1.39 and 95% CI, 1.34 to 1.44 for 30 to 44; HR, 2.28 and 95% CI, 2.19 to 2.39 for 15 to 29; HR, 3.26 and 95% CI, 3.05 to 3.49 for <15; and HR, 2.44 and 95% CI, 2.28 to 2.61 for those on dialysis. Relations were similar for the risk of hospitalization. The findings did not differ among patients with preserved or reduced systolic function, and hemoglobin level was an independent predictor of outcomes at all levels of kidney function. CONCLUSIONS: Very high (> or = 17 g/dL) or reduced (<13 g/dL) hemoglobin levels and chronic kidney disease independently predict substantially increased risks of death and hospitalization in heart failure, regardless of the level of systolic function. Randomized trials are needed to evaluate whether raising hemoglobin levels can improve outcomes in chronic heart failure.

Adult↗
PubMed2006

The Seattle Heart Failure Model: prediction of survival in heart failure.

BACKGROUND: Heart failure has an annual mortality rate ranging from 5% to 75%. The purpose of the study was to develop and validate a multivariate risk model to predict 1-, 2-, and 3-year survival in heart failure patients with the use of easily obtainable characteristics relating to clinical status, therapy (pharmacological as well as devices), and laboratory parameters. METHODS AND RESULTS: The Seattle Heart Failure Model was derived in a cohort of 1125 heart failure patients with the use of a multivariate Cox model. For medications and devices not available in the derivation database, hazard ratios were estimated from published literature. The model was prospectively validated in 5 additional cohorts totaling 9942 heart failure patients and 17,307 person-years of follow-up. The accuracy of the model was excellent, with predicted versus actual 1-year survival rates of 73.4% versus 74.3% in the derivation cohort and 90.5% versus 88.5%, 86.5% versus 86.5%, 83.8% versus 83.3%, 90.9% versus 91.0%, and 89.6% versus 86.7% in the 5 validation cohorts. For the lowest score, the 2-year survival was 92.8% compared with 88.7%, 77.8%, 58.1%, 29.5%, and 10.8% for scores of 0, 1, 2, 3, and 4, respectively. The overall receiver operating characteristic area under the curve was 0.729 (95% CI, 0.714 to 0.744). The model also allowed estimation of the benefit of adding medications or devices to an individual patient's therapeutic regimen. CONCLUSIONS: The Seattle Heart Failure Model provides an accurate estimate of 1-, 2-, and 3-year survival with the use of easily obtained clinical, pharmacological, device, and laboratory characteristics.

Adult↗
PubMed2001

Heart failure with a normal ejection fraction: is measurement of diastolic function necessary to make the diagnosis of diastolic heart failure?

BACKGROUND: The diagnosis of diastolic heart failure is generally made in patients who have the signs and symptoms of heart failure and a normal left ventricular (LV) ejection fraction. Whether the diagnosis also requires an objective measurement of parameters that reflect the diastolic properties of the ventricle has not been established. METHODS AND RESULTS: We hypothesized that the vast majority of patients with heart failure and a normal ejection fraction exhibit abnormal LV diastolic function. We tested this hypothesis by prospectively identifying 63 patients with a history of heart failure and an echocardiogram suggesting LV hypertrophy and a normal ejection fraction; we then assessed LV diastolic function during cardiac catheterization. All 63 patients had standard hemodynamic measurements; 47 underwent detailed micromanometer and echocardiographic-Doppler studies. The LV end-diastolic pressure was >16 mm Hg in 58 of the 63 patients; thus, 92% had elevated end-diastolic pressure (average, 24+/-8 mm Hg). The time constant of LV relaxation (average, 51+/-15 ms) was abnormal in 79% of the patients. The E/A ratio was abnormal in 48% of the patients. The E-wave deceleration time (average, 349+/-140 ms) was abnormal in 64% of the patients. One or more of the indexes of diastolic function were abnormal in every patient. CONCLUSIONS: Objective measurement of LV diastolic function serves to confirm rather than establish the diagnosis of diastolic heart failure. The diagnosis of diastolic heart failure can be made without the measurement of parameters that reflect LV diastolic function.

Cardiac Catheterization↗
PubMed2000

Organ system failures predict prognosis in critically ill patients with acute renal failure requiring dialysis.

BACKGROUND: Despite the widespread availability of dialytic and intensive care unit technology, the probability of early mortality in critically ill patients with acute renal failure is still high. Previous efforts to predict the outcome in this population have been limited by small sample sizes. In addition, data obtained decades ago may not apply today owing to changes in the case mix. We have attempted to determine whether organ system failures can be used to predict prognosis. METHODS: The medical records of 100 consecutive intensive care unit patients with acute renal failure who required dialysis from January 1997 through December 1998 were evaluated by a blinded reviewer. RESULTS: Of the 100 patients studied, 65 were men and 35 were women. The mean age of survivors and non-survivors was 59.4 +/- 20.3 years and 58.3 +/- 20.0 years, respectively. The overall mortality rate was 71%. There were no significant differences between survivors and non-survivors in age, gender, or indication for dialysis. The cause of death in the majority of patients was related to organ system failure, and they carried mortality rates exceeding 83% with the coexistence of four or more failed organs. CONCLUSION: The mortality rate for intensive care unit patients with acute renal failure continues to be high. Multiple organ system failure occurs frequently and is the major cause of death. The mortality rate increases as the number of failed organs increases.

Acute Kidney Injury↗
PubMed2000

[Fulminant hepatic failure. Atypical form of cardiac failure presentation].

Congestive liver disease can be one of the clinical aspects of chronic heart failure. Fulminant hepatic failure can be a consequence of ischemic liver disease secondary to cardiogenic shock. We report a patient with chronic heart failure who was admitted to our hospital presenting general malaise with abnormal liver function tests, prothrombin time and renal failure. The study of viral and autoimmune liver diseases were negative. She did not consume hepatotoxic drugs. She presented encephalopathy without initial evidence of shock. On the fourth day, she presented clinical deterioration compatible with cardiogenic shock. Laboratory abnormalities were similar to those seen in congestive and ischemic liver disease. The patient died 24 hours later. The histology showed congestive and ischemic liver disease. There are several reports of chronic liver diseases without a clear etiology, caused by constrictive pericarditis or restrictive myocardiopathy. In this case, the patient presented fulminant hepatic failure without clear evidence of progressive heart failure. We emphasize the importance of cardiac diseases as possible causes of liver diseases without another clear explanation.

Aged↗
PubMed2006

[Renal failure is an independent predictor of mortality in hospitalized heart failure patients and is associated with a worse cardiovascular risk profile].

INTRODUCTION AND OBJECTIVES: Most clinical trials that demonstrated the negative impact of renal failure on survival in patients with congestive heart failure (CHF) included a relatively small proportion of subjects with a high creatinine level and were performed in patients with depressed left ventricular systolic function. Our aim was to investigate the clinical characteristics and prognosis of hospitalized CHF patients with depressed or preserved systolic function and different degrees of renal dysfunction. PATIENTS AND METHOD: The study included 552 consecutive CHF patients admitted to a hospital department of cardiology between 2000-2002. Renal function was determined from the estimated glomerular filtration rate (GFR), and patients were divided into three groups: GFR>60, GFR 30-60, and GFR<30 mL.min per 1.73 m2 (severe renal failure), containing 56.5%, 35.5%, and 8.0% of patients, respectively. RESULTS: Patients with severe renal failure had the worst cardiovascular risk profile: older age, higher prevalence of cardiovascular risk factors, anemia, inflammatory markers in plasma, and less prescription of angiotensin-converting enzyme (ACE) inhibitors. Survival in this patient group was significantly poorer than in other groups (relative risk or RR=2.4; 95% CI, 1.3-4.4) in those with either depressed (RR=3.8; 95% CI, 1.4-10.6) or preserved (RR=2.9; 95% CI, 1.2-6.9) systolic function, independent of other prognostic factors. The negative impact of severe renal failure on prognosis was reduced by ACE inhibitor use. CONCLUSIONS: Renal failure is common and a strong predictor of mortality in hospitalized CHF patients with or without depressed systolic function. It is associated with a worse risk profile.

Age Factors↗
PubMed2006

[Prognostic value of symptoms and signs of advanced heart failure and low left ventricle ejection fraction in patients after myocardial infarction with chronic heart failure].

INTRODUCTION: Prognosis in patients (pts) after myocardial infarction (MI) with chronic heart failure (CHF) and asymptomatic left ventricular dysfunction (ALVD) differs. Acute coronary syndromes (ACS) worsen CHF and prognosis in these pts. A diagnostic tool that identifies the group of high risk pts is needed. Prognostic factors include left ventricle ejection fraction (LVEF) and stage of heart failure. The aim of the study was evaluation if decreased LVEF worsen prognosis in pts with CHF and ALVD and whether LVEF is more powerful predictor of poor prognosis than severity of heart failure. MATERIAL AND METHODS: 112 consecutive pts (95 men and 17 women age range 34-75, mean 52.9) post MI in stage B (ALVD) or stage C (CHF) according to ACC/AHA classification were studied. LVEF was determined in standard echocardiography with Simpson's method. Pts were divided into four groups: I--stage B and LVEF < or = 40% (6 pts); II--stage B and LVEF > 40% (52 pts); III--stage C and LVEF < or = 40% (19 pts); IV--stage C and LVEF > 40% (35 pts). The pts were followed for 30 months for the occurrence of the composite endpoint: major acute coronary events (MACE) i.e: ACS and cardiovascular deaths (CVD). In analysis we used chi2 test. RESULTS: There were 35 MACE during follow-up: 30 in pts in stage C and 5 in stage B. There were more MACE in group I than in group III (p < 0.01) and in group II than in group IV (p < 0.001). Pts in group I had more MACE than in group IV (p < 0.05). There were more MACE in group II than in group III (p < 0.01). Other results were not statistically significant. CONCLUSIONS: Stage of heart failure evaluated clinically is more powerful predictor of MACE than decreased LVEF. The more advanced stage of heart failure in post-MI pts, the higher risk of ACS or CVD. LVEF does not influence the risk of MACE in pts in the same stage of heart failure.

Adult↗
PubMed2006

Diastolic heart failure or heart failure with a normal ejection fraction.

Nearly half of patients with symptoms of heart failure are found to have an left ventricular (LV) ejection fraction which is within normal limits. These patients have variously been labeled as having diastolic heart failure, heart failure with preserved LV function or heart failure with normal ejection fraction (HFNEF). Since recent studies have shown that systolic function is not entirely normal in these patients, HFNEF is the better term. More common in elderly females it has a mortality similar to heart failure with a reduced ejection fraction (HFREF). The exact pathophysiology of the symtpoms is still not clear and, therefore, debated. As heart failure is often episodic, the underlying abnormal mechanisms may not be completely apparent at rest. It is likely there is a mixture of systolic and diastolic dysfunction which will be different to some degree in individual patients and isolated diastolic dysfunction or primary abnormalities of relaxation are probably extremely rare. The main difference between HFNEF and HFREF is the degree of ventricular remodeling with increased ventricular volumes in HFREF. The time course of remodeling depends to some extent on the aetiology being quicker post myocardial infarction--the commonest cause of HFREF, and slower with hypertension which is the most frequent aetiological factor in HFNEF. Ventricular volumes rather than ejection fraction or the concept of a pure diastolic abnormality can be used to classify patients in a more rational manner.

Aging↗
PubMed1995

Predictors of failure of high-frequency oscillatory ventilation in term infants with severe respiratory failure.

OBJECTIVE: To identify clinical factors in term neonates with severe respiratory failure that predict which neonates are unlikely to respond to high-frequency oscillatory ventilation (HFOV). DESIGN: This was a retrospective review of patient charts and medical records. PATIENTS: We studied 190 newborns treated with HFOV between July 1985 and December 1992. All patients were at least 35 weeks' estimated gestational age and had severe respiratory failure, defined as arterial to alveolar oxygen ratio (a/A ratio) of less than 0.2 or the need for peak inspiratory pressure greater than 35 cm H2O on conventional ventilation. RESULTS: Of the 190 patients, 111 (58%) responded to HFOV (HFOV responders), and 79 (42%) were placed on extracorporeal membrane oxygenation (ECMO) after HFOV failed to improve gas exchange (nonresponders). The two groups were similar in gender and birth weight. Factors associated with failure of HFOV to produce a sustained improvement in gas exchange were a diagnosis of congenital diaphragmatic hernia and more severe respiratory compromise as assessed by admission blood gas. Stepwise logistic regression analysis showed that a diagnosis of congenital diaphragmatic hernia/lung hypoplasia (CDH/LH) and the a/A ratio at initiation of and after 6 hours of HFOV were the only significant independent predictors of the need for ECMO. Among all the patients, the presence of CDH/LH or an initial a/A ratio of 0.05 or lower yielded a sensitivity of 74% and specificity of 77% in correctly identifying neonates in whom HFOV failed to produce a sustained improvement in oxygenation. When neonates with CDH/LH were excluded from analysis, the most significant predictor of failure of HFOV was the a/A ratio after 6 hours of HFOV. In neonates without CHD/LH, a 6-hour a/A ratio of 0.08 or lower discriminated responders from nonresponders (ie, treatment with ECMO) with a sensitivity of 77% and specificity of 92%. CONCLUSIONS: In our patients, the presence of CDH/LH, severe respiratory failure (a/A ratio 0.05 or lower) at initiation of HFOV, and lack of improvement in oxygenation (a/A ratio 0.08 or lower after 6 hours of HFOV) were associated with failure of HFOV and treatment with ECMO. This information should help other centers to identify neonates who are at the greatest risk for requiring ECMO support and thus allow prompt transfer to an ECMO center.

Acute Disease↗
PubMed1997

Randomised, placebo-controlled trial of carvedilol in patients with congestive heart failure due to ischaemic heart disease. Australia/New Zealand Heart Failure Research Collaborative Group.

BACKGROUND: In patients with heart failure, beta-blocker therapy improves left-ventricular function after 3-6 months of treatment, but effects of such treatment on symptoms and exercise performance are inconsistent, and the longer-term effects on death and other serious clinical events remain uncertain. We have investigated these issues in a double-blind, placebo-controlled, randomised trial of the beta-adrenergic blocker carvedilol (which also has alpha 1-blocking properties). METHODS: 415 patients with chronic stable heart failure were randomly assigned treatment with carvedilol (207) or matching placebo (208). At baseline, 6 months, and 12 months, we measured left-ventricular ejection fraction, left-ventricular dimensions, treadmill exercise duration, 6 min walk distance, New York Heart Association (NYHA) class, and specific activity scale (SAS) score. Double-blind follow-up continued for an average of 19 months, during which all deaths, hospital admissions, and episodes of worsening heart failure were documented. FINDINGS: After 12 months, left-ventricular ejection fraction had increased by 5.3% (2p < 0.0001) and end-diastolic and end-systolic dimensions had decreased by 1.7 mm (2p = 0.06) and 3.2 mm (2p = 0.001), respectively, in the carvedilol group compared with the placebo group. During the same period that were no clear changes in treadmill exercise duration, 6 min walk distance, NYHA class, or SAS score. After 19 months, the frequency of episodes of worsening heart failure was similar in the carvedilol and placebo groups (82 vs 75; relative risk 1.12 [95% Cl 0.82-1.53]) but the rate of death or hospital admission was lower in the carvedilol group than in the placebo group (104 vs 131; relative risk 0.74 [0.57-0.95]). INTERPRETATION: The beneficial effects of carvedilol on left-ventricular function and size were maintained for at least a year after the start of treatment, but carvedilol had no effect on exercise performance, symptoms, or episodes of worsening heart failure. There was an overall reduction in events resulting in death or hospital admission, and a year of treatment with carvedilol resulted in the avoidance of one such serious event among every 12-13 (SE 5) of these patients with chronic stable heart failure.

Adrenergic beta-Antagonists↗
PubMed1998

Continuous venovenous hemodialysis in multiple organ systems failure patients with acute renal failure.

BACKGROUND: Continuous renal replacement therapies have become the preferable methods for treating critically ill patients with acute renal failure. We studied the use of continuous venovenous hemodialysis (CVVHD) for the management of multiple organ failure patients with acute renal failure. MATERIALS AND METHODS: Forty patients in intensive care units were studied. Their mean age was 50.5 (range 21 to 82) years. The mean of number of organ system failures per patient was 4.9 (range 4 to 6). All patients required mechanical ventilation. CVVHD was performed from the femoral vein via a double-lumen catheter. Blood flow was maintained via blood pump at rate of 120 to 150 ml/min. Bicarbonate solution was delivered to the dialysate ports of the filter at rate of 700 to 900 ml/hour. Any complications during therapy were recorded. RESULTS: The mean urea clearance was 14.7 ml/min and the mean creatinine clearance was 15.4 ml/min. Electrolytes were all within the normal ranges. There were two episodes of extracorporeal circuit blood clotting and one patient experienced hypothermia. Seven of the 40 patients (17.5%) survived. CONCLUSION: CVVHD is a safe, effective, easily established therapy for managing the multiple organ failure patients with acute renal failure, offering good metabolic, electrolyte, and fluid control.

Acute Kidney Injury↗
PubMed2002

Management of heart failure in primary care (the IMPROVEMENT of Heart Failure Programme): an international survey.

BACKGROUND: Heart failure is a prevalent condition that is generally treated in primary care. The aim of this study was to assess how primary-care physicians think that heart failure should be managed, how they implement their knowledge, and whether differences exist in practice between countries. METHODS: The survey was undertaken in 15 countries that had membership of the European Society of Cardiology (ESC) between Sept 1, 1999, and May 31, 2000. Primary-care physicians' knowledge and perceptions about the management of heart failure were assessed with a perception survey and how a representative sample of patients was managed with an actual practice survey. FINDINGS: 1363 physicians provided data for 11062 patients, of whom 54% were older than 70 years and 45% were women. 82% of patients had had an echocardiogram but only 51% of these showed left ventricular systolic dysfunction. Ischaemic heart disease, hypertension, diabetes mellitus, atrial fibrillation, and major valve disease were all common. Physicians gave roughly equal priority to improvement of symptoms and prognosis. Most were aware of the benefits of ACE inhibitors and beta blockers. 60% of patients were prescribed ACE inhibitors, 34% beta blockers but only 20% received these drugs in combination. Doses given were about 50% of targets suggested in the ESC guidelines. If systolic dysfunction was documented, ACE inhibitors were more likely and beta blockers less likely to be prescribed than when there was no evidence of systolic dysfunction. INTERPRETATION: Results from this survey suggest that most patients with heart failure are appropriately investigated, although this finding might be as a result of high rates of hospital admissions. However, treatment seems to be less than optimum, and there are substantial variations in practice between countries. The inconsistencies between physicians' knowledge and the treatment that they deliver suggests that improved organisation of care for heart failure is required.

Aged↗