RESUMEN
BACKGROUND: Contrast media administered during cardiac catheterization can affect hemodynamic variables. However, little is documented about the effects of contrast on hemodynamics in heart failure patients or the prognostic value of baseline and changes in hemodynamics for predicting subsequent adverse events. METHODS AND RESULTS: In this prospective study of 150 heart failure patients, we measured hemodynamics at baseline and after administration of iodixanol or iopamidol contrast. One-year Kaplan-Meier estimates of adverse event-free survival (death, heart failure hospitalization, and rehospitalization) were generated, grouping patients by baseline measures of pulmonary capillary wedge pressure (PCWP) and cardiac index (CI), and by changes in those measures after contrast administration. We used Cox proportional hazards modeling to assess sequentially adding baseline PCWP and change in CI to 5 validated risk models (Seattle Heart Failure Score, ESCAPE [Evaluation Study of Congestive Heart Failure and Pulmonary Artery Catheterization Effectiveness], CHARM [Candesartan in Heart Failure: Assessment of Reduction in Mortality and Morbidity], CORONA [Controlled Rosuvastatin Multinational Trial in Heart Failure], and MAGGIC [Meta-Analysis Global Group in Chronic Heart Failure]). Median contrast volume was 109 mL. Both contrast media caused similarly small but statistically significant changes in most hemodynamic variables. There were 39 adverse events (26.0%). Adverse event rates increased using the composite metric of baseline PCWP and change in CI (P<0.01); elevated baseline PCWP and decreased CI after contrast correlated with the poorest prognosis. Adding both baseline PCWP and change in CI to the 5 risk models universally improved their predictive value (P≤0.02). CONCLUSIONS: In heart failure patients, the administration of contrast causes small but significant changes in hemodynamics. Calculating baseline PCWP with change in CI after contrast predicts adverse events and increases the predictive value of existing models. Patients with elevated baseline PCWP and decreased CI after contrast merit greatest concern.
Asunto(s)
Cateterismo Cardíaco/efectos adversos , Medios de Contraste/efectos adversos , Insuficiencia Cardíaca/diagnóstico , Hemodinámica/efectos de los fármacos , Yopamidol/efectos adversos , Ácidos Triyodobenzoicos/efectos adversos , Anciano , Gasto Cardíaco/efectos de los fármacos , Distribución de Chi-Cuadrado , Medios de Contraste/administración & dosificación , Supervivencia sin Enfermedad , Femenino , Insuficiencia Cardíaca/mortalidad , Insuficiencia Cardíaca/fisiopatología , Humanos , Yopamidol/administración & dosificación , Estimación de Kaplan-Meier , Modelos Lineales , Masculino , Persona de Mediana Edad , Readmisión del Paciente , Valor Predictivo de las Pruebas , Modelos de Riesgos Proporcionales , Estudios Prospectivos , Presión Esfenoidal Pulmonar/efectos de los fármacos , Medición de Riesgo , Factores de Riesgo , Factores de Tiempo , Ácidos Triyodobenzoicos/administración & dosificaciónAsunto(s)
Lesión Renal Aguda/inducido químicamente , Lesión Renal Aguda/diagnóstico por imagen , Angiografía Coronaria , Tomografía Computarizada por Rayos X , Ácidos Triyodobenzoicos/efectos adversos , Lesión Renal Aguda/epidemiología , Administración Intravenosa , Anciano , Estudios de Cohortes , Femenino , Humanos , Incidencia , Masculino , Persona de Mediana Edad , Estudios Retrospectivos , Ácidos Triyodobenzoicos/administración & dosificaciónRESUMEN
BACKGROUND: An altered diurnal blood pressure (BP) pattern has been linked to the risk of developing heart failure (HF). We tested whether an altered diurnal BP pattern is associated with adverse outcomes (death or hospitalization for HF exacerbation) in patients with HF. METHODS AND RESULTS: A total of 118 patients with HF were enrolled from a tertiary care HF clinic and followed for death or HF hospitalization for up to 4 years; 24-hour ambulatory BP was monitored. Forty patients (34%) had a normal BP dipping pattern (night-day ambulatory BP ratio < 0.9), 44 patients (37%) had a nondipping pattern (0.9 < or = night-day ambulatory BP ratio < 1.0), and 34 patients (29%) had a reverse dipping BP pattern (night-day ambulatory BP ratio > or = 1.0). A total of 39 patients had an adverse outcome. Adverse outcome rates were the lowest in dippers and the highest in reverse dippers (log rank P = .052). Predictors of adverse outcomes, selected on the basis of log likelihood contrast, were as follows: New York Heart Association functional class (hazard ratio [HR] 1.96, 95% confidence interval [CI] 1.11-3.44), anemia (HR 2.50, 95% CI 1.23-5.08), and dipping status (HR 1.65, 95% CI 1.08-2.50). CONCLUSION: In addition to other traditional predictors, BP dipping status may be an important prognostic factor in HF.
Asunto(s)
Presión Sanguínea/fisiología , Ritmo Circadiano/fisiología , Insuficiencia Cardíaca/mortalidad , Insuficiencia Cardíaca/fisiopatología , Hospitalización/tendencias , Anciano , Monitoreo Ambulatorio de la Presión Arterial/métodos , Muerte , Estudios de Seguimiento , Humanos , Masculino , Persona de Mediana Edad , Factores de RiesgoAsunto(s)
Neoplasias Cardíacas/diagnóstico , Linfoma de Células B/diagnóstico , Imagen por Resonancia Magnética , Anticuerpos Monoclonales/administración & dosificación , Anticuerpos Monoclonales de Origen Murino , Protocolos de Quimioterapia Combinada Antineoplásica/administración & dosificación , Protocolos de Quimioterapia Combinada Antineoplásica/uso terapéutico , Ciclofosfamida/administración & dosificación , Doxorrubicina/administración & dosificación , Ecocardiografía , Femenino , Citometría de Flujo , Atrios Cardíacos/patología , Neoplasias Cardíacas/tratamiento farmacológico , Ventrículos Cardíacos/patología , Humanos , Linfoma de Células B/tratamiento farmacológico , Persona de Mediana Edad , Derrame Pleural/etiología , Prednisona/administración & dosificación , Rituximab , Vincristina/administración & dosificaciónRESUMEN
OBJECTIVES: The purpose of this study was to investigate the possibility that some patients with coronary artery disease (CAD) but negative exercise or chemical stress test results might have mental stress-induced ischemia. The study population consisted solely of those with negative test results. BACKGROUND: Mental stress-induced ischemia has been reported in 20% to 70% of CAD subjects with exercise-induced ischemia. Because mechanisms of exercise and mental stress-induced ischemia may differ, we studied whether mental stress would produce ischemia in a proportion of subjects with CAD who have no inducible ischemia with exercise or pharmacologic tests. METHODS: Twenty-one subjects (14 men, 7 women) with a mean age of 67 years and with a documented history of CAD were studied. All subjects had a recent negative nuclear stress test result (exercise or chemical). Subjects completed a speaking task involving role playing a difficult interpersonal situation. A total of 30 mCi 99mTc-sestamibi was injected at one minute into the speech, and imaging was started 40 min later. A resting image obtained within one week was compared with the stress image. Images were analyzed for number and severity of perfusion defects. The summed difference score based on the difference between summed stress and rest scores was calculated. Severity was assessed using a semiquantitative scoring method from zero to four. RESULTS: Six of 21 (29%) subjects demonstrated reversible ischemia (summed difference score > or =3) with mental stress. No subject had chest pain or electrocardiographic changes during the stressor. Mean systolic and diastolic blood pressure and heart rate all increased between resting and times of peak stress. CONCLUSIONS: Mental stress may produce ischemia in some subjects with CAD and negative exercise or chemical nuclear stress test results.
Asunto(s)
Enfermedad de la Arteria Coronaria/complicaciones , Enfermedad de la Arteria Coronaria/psicología , Isquemia Miocárdica/etiología , Estrés Psicológico/complicaciones , Adenosina , Anciano , Anciano de 80 o más Años , Prueba de Esfuerzo , Femenino , Humanos , Masculino , Persona de Mediana EdadRESUMEN
Veterans with chronic heart failure (HF) are frequently elderly, have numerous comorbid chronic medical illnesses, frequent hospitalizations, and have high rates of cardiovascular events. Within the Veterans Health Administration (VHA), primary care providers are required to manage the majority of HF patients because access to cardiac specialty care within the VHA may be limited. We designed and implemented a care-coordinated, nurse-directed home telehealth management program for veterans with difficult-to-manage or new onset chronic systolic HF. An in-home telehealth message device was provided to the patient at enrollment, and patients received daily HF-specific education via the nurse coordinator and/or the device throughout their continuum of care. We collected demographic characteristics, clinical characteristics, and outcome data at the time of enrollment and at nearly 6 months after enrollment. A total of 92 patients were enrolled, with complete data available on 73. The mean patient age was 67 years, the mean left ventricular ejection fraction (LVEF) was 23%, and nearly all patients (99%) were men. After enrollment, significant improvements were found in blood pressure (129/73 to 119/69 mm Hg, p < 0.05), weight (196 to 192 pounds, p < 0.01), and shortness of breath rating (0-10 scale, 4.0 to 2.7, p = 0.02). Average daily doses of fosinopril (24 to 35 mg/d, p < 0.01) and metoprolol (84 to 94 mg/d, p = 0.05) were also improved. The total number of inpatient hospital days were reduced while on the home telehealth program (from 630 for the previous year to 122 for the duration of the program) with only 31% of the hospitalizations related to HF while on the program. Our nurse-directed, care coordinated home telehealth management program was associated with improved early outcomes in a group of elderly male veterans with chronic HF.
Asunto(s)
Insuficiencia Cardíaca/terapia , Servicios de Atención de Salud a Domicilio/organización & administración , Evaluación de Resultado en la Atención de Salud , Telemedicina , Veteranos , Anciano , Manejo de la Enfermedad , Femenino , Humanos , Masculino , Persona de Mediana Edad , Estados UnidosRESUMEN
Atherosclerosis is a disease process that affects the coronary, cerebral and peripheral arterial circulation. While great emphasis has been placed on the aggressive pharmacological management of coronary artery disease, less attention has been paid to the pharmacological management of peripheral vascular disease, despite its significant morbidity and mortality. The purpose of medical management in peripheral arterial disease is to relieve symptoms of claudication and to prevent thrombotic vascular events. These goals are best achieved through aggressive risk factor modification and pharmacotherapy. Risk factor modification includes smoking cessation, adequate control of blood pressure and cholesterol, as well as aggressive glycaemic control in patients with diabetes mellitus. Antiplatelet therapy and relief of claudication is also achieved through pharmacotherapy. With aggressive risk factor modification and adequate pharmacotherapy, patients with peripheral arterial disease can have an improved quality of life as well as prolonged survival.