Heart failure - implications of the true size of the problem

We review current knowledge on the true size of the clinical condition known as ‘heart failure’ in terms of epidemiological information and in relation to the true clinical burden.<p></p> Population studies, together with data from physician and general practitioner records, reveal a range of estimated heart-failure prevalence of 1–10%. Estimated incidence rates vary from approximately 0–1% per annum. Reasons for variation include age, sex and, possibly, methodology.<p></p> In community studies, the five-year mortality is between 50–60% while, in patients requiring hospital admission, the annual mortality is 10–20% in those with mild–moderate symptoms, and as high as 40–60% in severe heart failure.<p></p> While angiotensin-converting enzyme (ACE) inhibitor treatment does significantly improve mortality in all grades of symptomatic heart failure, the annual mortality in severe patients was still 36% in CONSENSUS I.<p></p> It is obvious that the term ‘heart failure’ is insufficiently descriptive or specific to be an acceptable label for all patients who might benefit from treatment.<p></p> As ‘clinical’ heart failure is often an advanced and irreversible state, studies of its antecedents are important in developing strategies aimed at retarding the progression from the asymptomatic to the symptomatic conditions. The true prevalence of the most common antecedent, left ventricular dysfunction, has received relatively little attention

Antioxidant potential of -SH containing angiotensin converting enzyme (ACE) inhibitors

No abstract available

Submaximal, but not maximal, exercise testing detects differences in the effects of beta-blockers during tredmill excerise: a study of Celiprolol and Atenolol

Celiprolol is a new-generation beta-blocker with ancillary properties that include partial beta 2-agonism and direct vasodilating activity. The effects of atenolol and celiprolol on maximal exercise capacity and on both respiratory variables and subjective indices of breathlessness and fatigue during submaximal exercise were compared in a placebo-controlled crossover study of 12 trained volunteers. Both atenolol and celiprolol equally and significantly reduced exercise capacity and maximal oxygen consumption. During constant submaximal exercise at 70% maximal oxygen uptake, however, differences emerged between the two beta-blockers. Atenolol was associated with a significantly higher minute ventilation than placebo. In contrast, values for minute ventilation and respiratory exchange ratio with celiprolol were similar to values with placebo. During the early stages of exercise, treatment with atenolol was also associated with higher scores for the subjective indices of breathlessness and fatigue. Thus submaximal exercise, which may be physiologically more relevant to the everyday activities of patients, may demonstrate potentially useful differences between drugs that are not seen during maximal exercise testing

The relation of arythmmias and electrolyte abnormalities to survival in patients with severe chronic heart failure

To investigate the determinants of mortality in patients with chronic congestive heart failure, we prospectively evaluated 84 patients with this disorder who underwent detailed biochemical, clinical, and functional tests at the time of initial evaluation and were then followed for 12 to 52 months (mean 31). During this period of follow-up, 58% of the patients died, of whom 71% died suddenly. The most important pretreatment predictor of mortality in these patients was the frequency of ventricular extrasystoles, followed by echocardiographic fractional shortening, a diagnosis of coronary artery disease, and duration of treadmill exercise. The finding of hypokalemia and hyponatremia in these patients at the time of entry into the study was associated with a poor prognosis by univariate analytical methods, but these electrolyte abnormalities did not provide independent prognostic information. The presence of ventricular arrhythmias was related to the severity of left ventricular dysfunction, exercise intolerance, and neurohormonal activation, suggesting that such arrhythmias are multifactorial in origin and may not simply be related to electrolyte abnormalities

Antioxidant effects of Angiotensin-Converting Enzyme (ACE) inhibitors: free radical and oxidant scavenging are sulfhydryl dependent, but lipid peroxidation is inhibited by both sulfhydryl- and nonsulfhydryl-containing ACE inhibitors

No abstract available

Ultrasound detection of cerebral emboli in patients with prosthetic heart valves

This study was undertaken in 64 patients, 50 with mechanical and 14 with porcine prosthetic valves, to evaluate the incidence of intracranial emboli and their distribution in the basal cerebral arteries. The patients were studied using transcranial Doppler (EME TC2-64B, Uberlingen, Germany), with a monitoring time of two minutes over each of the internal carotid arteries, middle and anterior cerebral arteries, vertebral arteries and the basilar artery. Sixty-three of the 64 patients were stabilized on warfarin at the time of the study. The incidence of emboli signals was significantly higher in patients with mechanical compared to porcine cardiac valves (88% versus 14%, p < 0.01). The number of emboli signals was significantly higher in the anterior compared with the posterior circulation, with a median of eight signals in the internal carotid arteries (95% confidence interval 5-15), 2.5 in the vertebral arteries (95% confidence interval 1-5.5)(p < 0.03). It was also significantly higher in those patients who had undergone double (aortic and mitral) as opposed to those who had undergone single aortic valve replacement: 18 versus two signals per minute (confidence intervals 5-30.5 versus 0.5-3.5) (p < 0.01). It is concluded that subclinical emboli signals are readily detectable using transcranial Doppler and are common in patients with prosthetic heart valves. Their number depends on both the type and the number of the prosthesis, while their distribution in the basal cerebral arteries is consistent with their cardiac source

Plasma TIMP-4 Predicts Left Ventricular Remodeling After Acute Myocardial Infarction

Background: Alterations in the balance between matrix metalloproteinases and their endogenous tissue inhibitors (TIMPs) are associated with left ventricular (LV) remodeling after acute myocardial infarction (AMI). No relationships have been identified between TIMPs and serial postinfarction change in LV function. Methods and Results: Plasma concentrations of TIMP-1, -2, -4 were measured at baseline (mean 46 h) and at 24 weeks in 100 patients (age 58.9 +/- 12 years, 77% male) admitted with AMI and LV dysfunction, with cardiac magnetic resonance imaging at each time point. TIMP-1 concentration was reduced, whereas TIMP-2 and -4 concentrations were elevated at baseline compared with a reference control population. TIMP-1 decreased and TIMP-2 increased significantly over time; there was an incremental trend in TIMP-4 concentration. Baseline TIMP-4 correlated with change in LV end-systolic volume index (Delta LVESVI; r = 0.24; P = .023) and change in LV end-diastolic volume index (Delta LVEDVI; r = 0.25; P = .015). Delta TIMP-4 also correlated with Delta LVESVI and with Delta LVEDVI, as did Delta TIMP-2. On multivariable analysis, baseline TIMP-4 concentration was an independent predictor of Delta LVESVI. Conclusions: Plasma TIMP-4 concentration, measured early after AMI, may assist in the prediction of LV remodeling and therefore in the assessment of prognosis. Further study of the role of the TIMPs in the pathophysiology of postinfarction remodeling is warranted