Calcium channel blockers in heart failure

AbstractThe rationale for the use of calcium enamel bleckers in patients with chronic heart failure lies in their vasodilator action, antiischemic effect, ability to lessen left ventricular diastole dysfunction and data showing their effect in preventing progression of myocardiai dysfunction in animals with cardiomyopathy. Despite initial studies reporting improvement of the hemodynamic profile with nifedipine, further evaluation showed variable results, with hemodynamic worsening seen in up to 29% of patients. Longer-term controued studies evaluating Symptoms and clinical status demonstrated worsening chronic heart failure in ~25% of patients within 8 weeks of nifedipine therapy. Although diltiazem has a lesser myo cardial depresseset effect and its short-term use was associated with less frequent hemodynamic and clinical worsening, long-tern exposure te the drug in a large group of paients with chronic heart failure due to left ventricular systolic dysfunction after myocardial infarction resulted in an increased incidence of cardiac events, with worsening heart failure and death. The use of verapamil in a simiar patient cohort showed the loss of its demostrated protective effect in patients with clinical evidence of heart failure.In an attempt to improve the safety of calcium channel blockers, the following approaches were suggested 1) use of second-generation drugs with less myocardial depressant effect; 2) concomitant use of angiotensin-converting enzyme inhibitors to prevent reported neurohormonal activation; and 3) development of drugs with favorable neurohormonal effects. These approaches led to mixed results. The use of some second-generation calcium channel blockers such as nisoldipine, felodipine and nicardipine resulted in no change or worsening of clinical status, which did not seem to be prevented by concomitant use of angiotensin-converting enzyme inhibitors. A recent study using amlodipine demonstrated improvement of both the clinical and neurohormonal profiles. Two large ongoing studies are evaluating the effects of felodipine and amlodipine on morbidity and mortality of patients with chronic heart failure and are likely to provide further information regarding the role of calcium blockers in the treatment of this condition

Influence of socioeconomic factors on pregnancy outcome in women with structural heart disease

OBJECTIVE: Cardiac disease is the leading cause of indirect maternal mortality. The aim of this study was to analyse to what extent socioeconomic factors influence the outcome of pregnancy in women with heart disease.  METHODS: The Registry of Pregnancy and Cardiac disease is a global prospective registry. For this analysis, countries that enrolled ≥10 patients were included. A combined cardiac endpoint included maternal cardiac death, arrhythmia requiring treatment, heart failure, thromboembolic event, aortic dissection, endocarditis, acute coronary syndrome, hospitalisation for cardiac reason or intervention. Associations between patient characteristics, country characteristics (income inequality expressed as Gini coefficient, health expenditure, schooling, gross domestic product, birth rate and hospital beds) and cardiac endpoints were checked in a three-level model (patient-centre-country).  RESULTS: A total of 30 countries enrolled 2924 patients from 89 centres. At least one endpoint occurred in 645 women (22.1%). Maternal age, New York Heart Association classification and modified WHO risk classification were associated with the combined endpoint and explained 37% of variance in outcome. Gini coefficient and country-specific birth rate explained an additional 4%. There were large differences between the individual countries, but the need for multilevel modelling to account for these differences disappeared after adjustment for patient characteristics, Gini and country-specific birth rate.  CONCLUSION: While there are definite interregional differences in pregnancy outcome in women with cardiac disease, these differences seem to be mainly driven by individual patient characteristics. Adjustment for country characteristics refined the results to a limited extent, but maternal condition seems to be the main determinant of outcome

Acute myocardial infarction associated with pregnancy.

November 1996 | Volume 125 Issue 9 | Pages 751-762 Purpose: To review available information on the epidemiology, cause, diagnosis, prognosis, and treatment of acute myocardial infarction during pregnancy or in the early postpartum period and to develop guidelines for the management of this condition. Data Sources: MEDLINE and Index Medicus searches and a manual search of bibliographies from reviewed articles. Study Selection: Published reports of well-documented acute myocardial infarction during pregnancy or the early postpartum period or potentially relevant information. Data Extraction: 125 well-documented cases of myocardial infarction were identified. Data Synthesis: The highest incidence seems to occur in the third trimester and in multigravidas older than 33 years of age. Acute myocardial infarction during pregnancy is most commonly located in the anterior wall. The maternal death rate was 21%; death occurred most often at the time of acute myocardial infarction or within 2 weeks of the infarction and was usually related to labor and delivery. Most fetal deaths were associated with maternal deaths. Coronary artery morphology was studied in 54% of described patients. Coronary atherosclerosis with or without intracoronary thrombus was found in 43% of patients, coronary thrombus without atherosclerotic disease in 21%, coronary dissection in 16%, and normal coronary arteries in 29%. Conclusions: Acute myocardial infarction during pregnancy or the early postpartum period is rare but may be associated with high risk. Although atherosclerosis can be documented in many cases, coronary dissection and arteries that are normal on angiography are common, especially in acute myocardial infarction occurring in the peripartum or postpartum period. Early diagnosis is often hindered by the normal changes of pregnancy and low level of suspicion. Management should follow the usual principles of care for acute myocardial infarction. However, selection of diagnostic and therapeutic approaches may be greatly influenced by fetal safety. Acute myocardial infarction rarely occurs in women of childbearing age and has been estimated to occur in only 1 in 10 000 women during pregnancy Methods A literature search for acute myocardial infarction during pregnancy was done using MEDLINE and Index Medicus. All original articles were obtained from the University of Southern California library, interlibrary communications, or the authors of the articles. Translators were used to translate all original articles written in foreign languages. Only cases of acute myocardial infarction that were documented by chest pain, standard electrocardiographic criteria, and enzymatic changes (or histologic changes in patients who died) were selected for review. Six cases that were described as acute myocardial infarction but did not fulfill the aforementioned criteria were excluded from the analysis. Epidemiologic data were used to compare selected patients who had acute myocardial infarction in the antepartum (as many as 24 hours before labor), peripartum (within 24 hours before or after delivery), and postpartum (from 24 hours to 3 months after delivery) periods. We make recommendations on the basis of available information, with the understanding that the 125 case