Evaluation of the clinical relevance of baseline left ventricular ejection fraction as a predictor of recovery or persistence of severe dysfunction in women in the United States with peripartum cardiomyopathy.

BACKGROUND: Baseline left ventricular ejection fraction (LVEF) has been shown to be associated with likelihood of recovery in patients with peripartum cardiomyopathy (PPCM). The clinical relevance of this association for individual patients is unclear. METHODS AND RESULTS: We analyzed baseline parameters of LVEF in 187 PPCM patients with ≥6 months follow-up data in an attempt to detect the value of baseline LVEF as a predictor of early recovery or persistence of severe LV dysfunction. Recovery of LV function (LVEF ≥50%) at 6 months after diagnosis was found in 115 patients (61%). Multivariate analysis identified baseline LVEF >30% as a significant predictor for recovery (odds ratio 5.2, 95% confidence interval 1.96-7.70; P > .0001). Recovery of LV function was 6.4-fold higher in women with baseline LVEF ≥ 30% (group III) and 3.9-fold higher in women with LVEF 20%-29% (group II) compared with those with LVEF 10%-19% (group I). Failure to achieve full recovery was seen in 63% of group I patients, 32% of group II (P = .03), and 21% of group III (P = .02 vs group I). Failure to achieve LVEF ≥30% was seen in 30% of group I patients and 13% of group II (P = .09). CONCLUSIONS: Early recovery in patients with PPCM is significantly related to the degree of myocardial insult at time of diagnosis. Baseline LVEF however, has a limited sensitivity for prediction of failure to improve in individual patients and can not be used as an indication for premature use of aggressive therapy including devices or cardiac transplantation.

Clinical profile and predictors of complications in peripartum cardiomyopathy.

BACKGROUND: Clinical profile and predictors of major adverse events (MAE) associated with peripartum cardiomyopathy (PPCM) have not been characterized. METHODS AND RESULTS: A retrospective review and analysis of clinical data of 182 patients with PPCM. Forty-six patients had >or=1 MAE, including death (13), heart transplantation (11), temporary circulatory support (4), cardiopulmonary arrest (6), fulminant pulmonary edema (17), thromboembolic complications (4), and defibrillator or pacemaker implantation (10). Diagnosis of PPCM was delayed >or=1 week in 48% of patients with MAE that preceded the diagnosis in 50% of these patients. Seven (32%) of the surviving patients who had MAE and did not undergo heart transplantation had residual brain damage. Significant predictors of MAE were: left ventricular ejection fraction

Variable response of conductance and resistance coronary arteries to endothelial stimulation in patients with heart failure due to nonischemic dilated cardiomyopathy.

UNLABELLED: Attenuation of endothelial-dependent coronary vasodilation has been reported in idiopathic dilated cardiomyopathy and anatomically normal coronaries; however, data are insufficient for understanding the incidence and extent of this finding. The response of conductance and resistance coronary arteries to endothelial stimulation with acetylcholine was examined in 25 patients. Coronary blood flow had a variable response to acetylcholine and suggested coronary endothelial dysfunction in approximately half of the patients. Abnormal endothelial dysfunction involved the large conductance epicardial coronary arteries and the small resistance vessels. Abnormal endothelial response of coronary blood flow to acetylcholine could not be predicted by demographic and hemodynamic data. CONCLUSIONS: Coronary artery endothelial function is heterogeneous in patients with idiopathic dilated cardiomyopathy. Endothelial dysfunction is present in approximately half of the cases and involves both resistance as well as conductance coronary blood vessels. Furthermore, coronary endothelial function cannot be predicted by demographic and hemo-dynamic parameters or left ventricular ejection fraction.

Effects of nitrates and hydralazine in heart failure: clinical evidence before the african american heart failure trial.

The initial rationale for use of organic nitrates and hydralazine (HYD) in combination was their complementary "nitroprussidelike" hemodynamic effect caused by the predominant venodilatory action of organic nitrates and the arterial-dilatory effect of HYD. This combination leads to a significant improvement in cardiac function, with a concomitant reduction in right and left ventricular filling pressures and augmentation of cardiac output. Based on this hemodynamic profile, the Vasodilator Heart Failure Trial (V-HeFT) was designed to examine the effect of this drug combination on the outcome of patients with congestive heart failure (CHF). Results from V-HeFT I showed improvements in left ventricular ejection fraction (LVEF), exercise tolerance, and survival in patients treated with isosorbide dinitrate (ISDN) and HYD compared with those treated with placebo. A retrospective analysis of V-HeFT I and V-HeFT II showed that the benefit of ISDN-HYD was seen mainly in African Americans. This observation led to the design of the African American Heart Failure Trial (A-HeFT), which confirmed the benefit of these drugs in combination in African American patients with CHF. There are a number of potential mechanisms responsible for the beneficial therapeutic effects of combination ISDN-HYD in patients with CHF, including favorable hemodynamic effects and improvement in left ventricular systolic function. Data from V-HeFT II showed a significant improvement in LVEF with combination ISDN-HYD, greater than the effect of the angiotensin-converting enzyme inhibitor enalapril. This increase in LVEF was associated with a favorable effect on survival. Prevention of nitrate tolerance with HYD may also be responsible for the favorable therapeutic effects of combination ISDN-HYD. Frequent administration of ISDN has been shown to result in the early development of nitrate tolerance. Concomitant use of HYD with a nitrate, both in an animal model and in patients with CHF, has been shown to prevent the development of nitrate tolerance and maintain the favorable hemodynamic effect of nitrates.

Valvular heart disease and pregnancy: part II: prosthetic valves.

A large number of prosthetic heart valves (PHV) are being implanted in patients with both congenital and acquired valvular disease. Many of the recipients of such valves are women of childbearing age who desire to have children. The main issues involved with pregnancy in a patient with PHV include the selection of PHV in women during their childbearing age, risks to both the mother and the fetus associated with pregnancy and the management of the patients with PHV during gestation.

Left atrial thrombosis in pregnant women with mitral stenosis and sinus rhythm.

OBJECTIVE: The purpose of this study was to describe pregnant patients with mitral stenosis who had intracardiac thrombosis in the absence of atrial fibrillation. STUDY DESIGN: We reviewed the clinical course of 3 pregnant women with severe mitral stenosis and normal sinus rhythm who had clinically significant intracardiac thrombosis. RESULTS: The first patient was examined at 21 weeks of gestation with embolic stroke that was the result of left atrial thrombus. A second patient was found to have a large left atrial thrombus that prevented the performance of balloon valvuloplasty. The third patient had left atrial clot that partially occluded the mitral valve orifice and led to the development of pulmonary edema that resulted in an emergent cesarean delivery and anoxic brain injury in the newborn infant. CONCLUSION: Pregnant patients with mitral stenosis in normal sinus rhythm can experience thromboembolic events that can be detrimental to both the mother and the fetus. Anticoagulation therefore should be strongly considered in this group.

Valvular heart disease and pregnancy part I: native valves.

Pregnancy in patients with valvular heart disease (VHD) continues to pose a challenge to both physicians and their patients and could be associated with an unfavorable maternal as well as fetal outcome. The purpose of this paper is to review the available clinical data and provide recommendations for the management of patients with VHD during gestation.

Pregnancy-associated cardiomyopathy: clinical characteristics and a comparison between early and late presentation.

BACKGROUND: Cardiomyopathy associated with pregnancy was first described more than half a century ago. However, because of its rare occurrence and geographical differences, the clinical profile of this condition has remained incompletely defined. METHODS AND RESULTS: Data obtained from 123 women with a history of cardiomyopathy diagnosed during pregnancy or the postpartum period were reviewed. One hundred women met traditional criteria of peripartum cardiomyopathy; 23 were diagnosed with pregnancy-associated cardiomyopathy earlier than the last gestational month. Peripartum cardiomyopathy patients had a mean age of 31+/-6 years and were mostly white (67%). Common associated conditions were gestational hypertension (43%), tocolytic therapy (19%), and twin pregnancy (13%). Left ventricular ejection fraction at the time of diagnosis was 29+/-11% and improved to 46+/-14% (P< or =0.0001) at follow-up. Normalization of left ventricular ejection fraction occurred in 54% and was more likely in patients with left ventricular ejection fraction >30% at diagnosis. Maternal mortality was 9%. A comparison between the peripartum cardiomyopathy and early pregnancy-associated cardiomyopathy groups revealed no differences in age, race, associated conditions, left ventricular ejection fraction at diagnosis, its rate and time of recovery, and maternal outcome. CONCLUSIONS: This study helps to define the clinical profile of patients with pregnancy-associated cardiomyopathy diagnosed in the United States. Clinical presentation and outcome of patients with pregnancy-associated cardiomyopathy diagnosed early in pregnancy are similar to those of patients with traditional peripartum cardiomyopathy. These 2 conditions may represent a continuum of a spectrum of the same disease.

Survey of the use of organic nitrates for the treatment of chronic congestive heart failure in the United States.

A survey of members of the Heart Failure Society of America revealed that despite their lack of approval by the United States Food and Drug Administration, nitrates are widely used in patients with chronic congestive heart failure (CHF). Most members reported using nitrates in patients with ischemic (90%) and nonischemic (81%) causes of chronic CHF, especially those with symptomatic CHF (43% reported using nitrates in >50% of their patients with ischemic and 25% with nonischemic causes). Ninety-six percent reported using nitrates to reduce symptoms, 74% for hemodynamic improvement, 65% for better exercise tolerance, and only 14% for left ventricular reversed remodeling. Nitrates were always combined with hydralazine in 25% of patients and occasionally combined with hydralazine in 67%.

Effect of elevated admission serum creatinine and its worsening on outcome in hospitalized patients with decompensated heart failure.

Renal insufficiency (RI), as represented by elevated serum creatinine (>1.5 mg/dl) on admission, is common and found in almost half of patients hospitalized with decompensated heart failure. This finding is associated with prolongation of length of stay and rate of rehospitalizations after discharge and also has an independent unfavorable effect on 6-month mortality. Similarly, an increase in serum creatinine (>0.5 mg/dl) in the hospital results in a significantly longer length of stay and has an independent effect on long-term mortality.

Intravenous nitroglycerin in the treatment of decompensated heart failure: potential benefits and limitations.

Acute decompensated heart failure (ADHF) is a common cause of hospitalizations. Intravenous nitroglycerin is widely used in the treatment of this condition. The use of this drug is based on its nitric oxide-mediated vasodilatory effect, which can lead to beneficial hemodynamic effects as well as improvement of myocardial ischemia and reduction of mitral regurgitation. However, information regarding the use of nitroglycerin for ADHF is limited to mostly hemodynamic evaluations in small groups of patients without cardiovascular outcome data. A single randomized, placebo controlled study that evaluated commonly used doses of nitroglycerin in patients with ADHF was disappointing and failed to show a significant hemodynamic effect or improvement of symptoms compared with placebo. The potential benefit of nitroglycerin seems to be limited by a decreased vasodilatory response in patients with heart failure, which requires an active titration of the drug and the use of high doses (>120 microg/min). In addition, the initial beneficial hemodynamic effect achieved with the appropriate dose of nitroglycerin is associated with neurohumoral activation and limited by an early development of nitrate tolerance that leads to a marked attenuation of the initial effect. More information obtained in large-scale studies that are appropriately designed to evaluate the effect of variable doses of nitroglycerin on short- and long-term cardiovascular outcome, with and without interventions shown to prevent nitrate tolerance, is needed before intravenous nitroglycerin can be recommended as a standard therapy for ADHF.