Value of neurohormonal and autonomic parameters for the assessment of the severity and prognosis in chronic heart failure

The aim of this thesis was threefold: 1. to evaluate diagnostic tools to monitor parients with CHF. 2. to study the progression and prognosis of CHF. 3. to study drugs which are considered to have an effect on the autonomic and neurohormonal profile of patients with CHF. Zie: Summary

Divergence between growth hormone responses to insulin-induced hypoglycaemia and growth hormone-releasing hormone in patients with non-functioning pituitary macroadenomas and hyperprolactinaemia

OBJECTIVE The GH responses to the insulin tolerance test (ITT) and growth hormone-releasing hormone (GHRH) may yield different results in patients with pituitary lesions. The GH responses to these stimuli were compared in patients with untreated non-functioning pituitary macroadenomas, who represent an important cause of GH deficiency. DESIGN Analysis of peak on to ITT and to 100 mu g GHRH in relation to an elevated PRL level (> 200 mIU/l for males and > 600 mIU/l for females) as an indication of hypothalamic-pituitary dysregulation, as well as in relation to other anterior pituitary hormone deficiencies. A peak GH <5 mu g/l in either test indicated GH deficiency. PATIENTS Twenty females and 14 males (median age 52 (23-77) years) evaluated preoperatively in a university hospital setting. RESULTS In the whole group the median peak GH to GHRH (3.6 (0.9-26.3) mu g/l) was higher than to ITT (1.6 (0.2-7.8) mu g/l, P <0.001). This difference was seen only in 19 patients with concomitant hyperprolactinaemia (P <0.001). When hyperprolactinaemia was present, an insufficient GH peak was demonstrated by ITT in 16 cases and by GHRH stimulation in 7 cases (P <0.01). The frequency of an insufficient GH peak by ITT (13 cases) and by GHRH (14 cases) was similar in the normoprolactinaemic patients. In addition, 9 of 10 patients with an impaired response to ITT and a normal response to GHRH were hyperprolactinaemic compared to 7 of 19 patients with GH deficiency as assessed by both stimuli (P <0.02). Peak GH to ITT was lower in 24 patients with, compared to 10 patients without, other hormonal deficiencies (1.4 (0.2-5.6) vs 3.0 (1.0-7.8) mu g/l, P <0.02), but was not related to elevated PRL. In contrast, GHRH-stimulated GH was higher in hyperprolactinaemic than in normoprolactinaemic patients (5.9 (1.6-26.3) vs 2.9 (0.9-5.4) mu g/l, P <0.001) and was not related to the presence of other pituitary hormone deficiencies. Analysis of covariance confirmed that peak GH to ITT was negatively associated with the presence of other pituitary hormone deficiencies (P <0.01), whereas peak GH to GHRH was positively related to an elevated PRL level (P <0.02). nasal GH was positively correlated with PRL (R(s) = 0.36, P <0.05). CONCLUSIONS This study demonstrates that ITT and GHRH tests cannot be used interchangeably in diagnosing GH deficiency in patients with non-functioning pituitary macroadenoma and hyperprolactinaemia. If the ITT is considered to be the reference test, GH deficiency as assessed by GHRH can be missed in patients with hyperprolactinaemia. This disparity is probably due to a different mechanism of action of these stimuli. Hyperprolactinaemia may be associated with a diminished somatostatin tone, leading to a higher basal and GHRH-stimulated GH, without having an effect on peak GH to ITT

Hyperprolactinaemia is associated with a higher prevalence of pituitary-adrenal dysfunction in non-functioning pituitary macroadenoma

In non-functioning pituitary macroadenoma (NFMA), hyperprolactinaemia (hyperPRL) is considered to be a sign of hypothalamic-pituitary dysregulation, but it is unknown whether hyperPRL is associated with an increased frequency of pituitary hormone deficiencies. Forty consecutive patients with histology-proven NFMA were studied and hyperPRL was defined as serum prolactin (PRL) >200 mIU/l in men and >600 mIU/l in women. The pituitary-adrenal axis was evaluated by measurement of urinary free cortisol (N=38), peak cortisol to insulin-induced hypoglycaemia (IIH, N=36) and to human corticotrophin-releasing hormone (hCRF, N=40) and by urinary tetrahydro-11-deoxycortisol (H4S, N=39), plasma androstenedione increment (N=39) and serum 11-deoxycortisol (N=1) after metyrapone. Central hypothyroidism, gonadotrophin deficiency and growth hormone (GH) reserve were also assessed. Twenty patients had hyperPRL (serum PRL 331 (223-1120) mIU/l (median, range) in men and 932 (660-3927) mIU/l in women); urinary free cortisol excretion (

Rapid bedside measurement of brain natriuretic peptide in patients with chronic heart failure

Background: Brain natriuretic peptide (BNP) levels have been used to assess clinical status and predict prognosis of patients with chronic heart failure (CHF). However, BNP levels can only be measured in specialized laboratories which has hampered its use in daily clinical practice. We compared a new, rapid, BNP assay with a conventional BNP measurement and evaluated the applicability to current practice by comparing it with standard clinical parameters. Methods: BNP levels were determined in 78 stable CHF patients and 20 controls. The severity of CHF was assessed by determination of New York Heart Association functional class (NYHA), left ventricular ejection fraction (LVEF) and peak oxygen consumption (peak Vo(2)), and these parameters were compared to BNP levels. Results: Overall, rapid BNP assessment was highly correlated with the conventional BNP assay (r = 0.95, P 200 pmol/l), however, correlation was less accurate, and tended to overestimate. BNP levels also strongly correlated with both NYHA class, LVEF and peak Vo2 (all P <0.001). A cut-off value for BNP of 20 pmol/l yielded a sensitivity of 91% and a specificity of 92% to detect the presence of left ventricular systolic dysfunction. Conclusions: Rapid measurement of BNP levels is comparable to conventional BNP measurement and strongly correlated to clinical tests that are currently used to stratify CHF patients. Wider use of this method may yield a reduction of costly and time-consuming clinical tests and may reduce the medical burden of CHF. (C) 2002 Elsevier Science Ireland Ltd. All rights reserved

Early or late intervention in patients with transient ST-segment elevation acute coronary syndrome: Subgroup analysis of the ELISA-3 trial

Item does not contain fulltextOBJECTIVES: To investigate incidence and patient characteristics of transient ST-segment elevation (TSTE) ACS and to compare outcome of early versus late invasive treatment. BACKGROUND: Optimal timing of treatment in TSTE-ACS patients is not outlined in current guidelines and no prospective randomized trials have been done so far. METHODS: Post hoc subgroup analysis of patients with TSTE randomized in the ELISA 3 trial. This study compared early (48 h) angiography and revascularization in 542 patients with high-risk NSTE-ACS. Primary endpoint was incidence of death, reinfarction, or recurrent ischemia at 30 days follow-up. RESULTS: TSTE was present in 129 patients (24.2%) and associated with male gender, smoking and younger age. The primary endpoint occurred in 8.9% of patients with and 13.0% of patients without TSTE (RR = 0.681, P = 0.214). Incidence of death or MI after 2 year follow-up was 5.7 and 14.6% respectively (RR = 0.384, P = 0.008). Within the group of patients with TSTE, incidence of the primary endpoint was 5.8% in the early and 12.7% in the late treatment group (RR = 0.455, P = 0.213), driven by reduction in recurrent ischemia. Enzymatic infarct size, bleeding and incidence of death or recurrent MI at 2 years follow-up was comparable between the treatment groups. CONCLUSIONS: In high-risk patients with NSTE-ACS, TSTE is frequently seen. Similar to findings in patients with high-risk NSTE-ACS, immediate angiography and revascularization in these patients is feasible but not superior to later treatment. Prospective randomized trials are needed to provide more evidence in the optimal timing of treatment in patients with TSTE-ACS. (c) 2016 Wiley Periodicals, Inc

Comparison of Outcomes and Intervention Among Patients With Non-ST-Segment Elevation Acute Myocardial Infarction of Those With a Left Circumflex Versus Those With a Non-Left Circumflex-Related Coronary Artery (From the ELISA-3 Trial)

Previous studies found that patients with an acute coronary syndrome (ACS) due to occlusion of the left circumflex (LC) coronary artery often present without ST-elevation, leading to a delay in diagnosis and revascularization, a larger infarct size, and a worse prognosis. In this subgroup analysis of the ELISA-3 study (early or late intervention in high-risk non-ST-segment elevation acute coronary syndromes [NSTE-ACS]) incidence, characteristics and prognosis of LC-related NSTE-ACS was investigated, and the outcome of early versus late invasive strategy was compared. In 383 of 542 patients the culprit vessel could be identified, with the LC artery in 112 (29%) of them. Patients with LC-related ACS had more often single vessel disease and underwent percutaneous coronary intervention more and CABG less frequently. The primary end point of the combined incidences of death, myocardial infarction, and recurrent ischemia at 30-day follow-up occurred in 9.0% of LC versus 16.5% of non-LC-related ACS (p = 0.057). Enzymatic infarct size and incidence of bleeding were comparable. Of patients with LC-related ACS, 62 were assigned to an early and 50 to a late invasive treatment with a median time from admission to angiography of 5.5 and 65.7 hours, respectively. The primary end point occurred in 9.7% and 8.0%, respectively (p = 1.00) with comparable enzymatic infarct size and bleeding. In conclusion, no significant differences in outcome were found between patients with an LC- and a non-LC-related NSTE-ACS. In LC-related NSTE-ACS, angiography within 12 hours of admission is feasible but not superior to angiography after more than 48 hours. (C) 2018 Elsevier Inc. All rights reserved