Improving survival for patients with advanced heart failure: A study of 737 consecutive patients

Objectives.This study sought to determine whether survival and risk of sudden death have improved for patients with advanced heart failure referred for consideration for heart transplantation as advances in medical therapy were systematically implemented over an 8-year period.Background.Recent survival trials in patients with mild to moderate heart failure and patients after a myocardial infarction have shown that angiotensin-converting enzyme inhibitors are beneficial, type I antiarrhythmic drugs can be detrimental, and amiodarone may be beneficial in some groups. The impact of advances in therapy may be enhanced or blunted when applied to severe heart failure.Methods.One-year mortality and sudden death were determined in relation to time, baseline variables and therapeutics for 737 consecutive patients referred for heart transplantation and discharged home on medical therapy from 1986 to 1988, 1989 to 1990 and 1991 to 1993. Medical care was directed by a single team of physicians with policies established by consensus. From 1986 to 1990, the hydralazine/isosorbide dinitrate combination or angiotensin-converting enzyme inhibitors were the initial vasodilators, and class I antiarrhythmic drugs were allowed. After 1990, captopril was the initial vasodilator, given to 86% of patients compared with 46% of patients before 1989. After mid-1989, class I agents were routinely withdrawn, and amiodarone was used for frequent ventricular ectopic beats or atrial fibrillation (53% of patients after 1990 vs. 10% before 1989).Results.The total 1-year mortality rate decreased from 33% before 1989 to 16% after 1990 (p = 0.0001), and sudden death decreased from 20% to 8% (p = 0.0006). Adjusted for clinical and hemodynamic variables in multivariate proportional hazards models, total mortality and sudden death were lower after 1990.Conclusions.The large reduction in mortality, particularly in sudden death, from advanced heart failure since 1990 may reflect an enhanced impact of therapeutic advances shown in large randomized trials when they are incorporated into a comprehensive approach in this population. This improved survival supports the growing practice of maintaining potential heart transplant candidates on optimal medical therapy until clinical decompensation mandates transplantation

Prediction of improvement of contractile function in patients with ischemic ventricular dysfunction after revascularization by fluorine-18 fluorodeoxyglucose single-photon emission computed tomography

Objectives. We evaluated the use of fluorine-18 fluorodeoxyglucose (FDG) and single-photon emission computed tomography (SPECT) to predict improvement of left ventricular ejection fraction (LVEF) after revascularization. Background. FDG SPECT has recently been proposed for assessment of myocardial viability. However, FDG SPECT still awaits validation in terms of predicting improvement of contractile function after revascularization in patients with poor left ventricular (LV) function. Methods. Fifty-five patients with contractile dysfunction (including 22 with LVEF <30%) underwent FDG SPECT during hyperinsulinemic glucose clamping and early thallium-201 SPECT (to assess perfusion). Improvement of LV function was evaluated 3 months after revascularization with echocardiography and radionuclide ventriculography. Results. The 55 patients were arbitrarily classified into two groups: 19 with three or more viable, dysfunctional segments on FDG SPECT and 36 with less than three viable, dysfunctional segments. LVEF increased significantly in the first group, from 28 ± 8% (mean ± SD) before to 35 ± 9% (p < 0.01) after revascularization. In the second group, LVEF remained unchanged after revascularization (45 ± 14% vs. 44 ± 14%, p = NS). The 22 patients with severely depressed LV function were similarly classified into two groups: 14 with three or more viable segments on FDG SPECT in whom LVEF improved significantly (25 ± 6% vs. 32 ± 6%) and 8 with less than three viable segments in whom LVEF remained unchanged (24 ± 6% vs. 25 ± 6%). Conclusions. This study shows that FDG SPECT can identify patients in whom LV function improves after revascularization. Because SPECT is widely available, this technique may contribute to more routine use of FDG for determination of viability

Healing Words: Using Affect Labeling to Reduce the Effects of Unpleasant Cues on Symptom Reporting in IBS Patients

Purpose: The present study aimed to induce elevated symptom reports through the presentation of unpleasant cues in patients with irritable bowel syndrome (IBS) and examine whether applying an emotion regulation technique (affect labeling) can reduce symptom reporting in patients. Methods: Patients diagnosed with IBS (N = 29) and healthy controls (N = 26) were presented with six picture series (three pleasant, three unpleasant) under three within-subject conditions: merely viewing, emotional labeling, or content (non-emotional) labeling. Each picture viewing trial was followed by affect ratings and a symptom checklist, consisting of general arousal and IBS-specific symptoms. Results: Viewing unpleasant pictures led to overall increased symptom reports, both for arousal and gastrointestinal symptoms, in both groups. Labeling the pictures did not reduce these effects significantly, although a trend toward less arousal symptoms after unpleasant cues emerged in the patient group only, especially during emotional labeling. Conclusions: Current findings indicate that the mere presentation of unpleasant cues can induce elevated symptom reports in IBS patients. The results of the labeling manipulation provide modest support for the effectiveness of emotion regulation strategies in reversing these effects of unpleasant cues in patients suffering from functional syndromes. Methodological issues that may have confounded present results are discussed.</p

Accuracy of currently available techniques to predict functional recovery after revascularization in patients with left ventricular dysfunction due to chronic coronary artery disease: comparison of pooled data

Objectives. This study evaluated the relative merits of the most frequently used techniques for predicting improvement in regional contractile function after coronary revascularization in patients with left ventricular dysfunction due to chronic coronary artery disease. Background. Several techniques have been proposed for predicting improvement in regional contractile function after revascularization, including thallium-201 (TI- 201) stress-redistribution-reinjection, T1-201 rest-redistribution, fluorine- 18 fluorodeoxyglucose with positron emission tomography, technetium-99m sestamibi imaging and low dose dobutamine echocardiography (LODE). Methods. A systematic review of all reports on prediction of functional recovery after revascularization in patients with chronic coronary artery disease (published between 1980 and March 1997) revealed 37 with sufficient details for calculating the sensitivity and specificity of each imaging morality. From the pooled data, 95% and 99% confidence intervals were also calculated. Results. Sensitivity for predicting regional functional recovery after revascularization was high for all techniques. The specificity of both T1- 201 protocols was significantly lower (p < 0.05) and LDDE significantly higher (p < 0.01) than that of the other techniques. Conclusions. Pooled analysis of 37 studies showed that although all techniques accurately identify segments with improved contractile function after revascularization, the T1-201 protocols may overestimate functional recovery. The evidence available thus far indicates that LDDE appears to have the highest predictive accuracy