The beneficial role of spiritual counseling in heart failure patients.

To ascertain the beneficial role of spiritual counseling in patients with chronic heart failure. This is a pilot study evaluating the effects of adjunct spiritual counseling on quality of life (QoL) outcomes in patients with heart failure. Patients were assigned to "religious" or "non-religious" counseling services based strictly on their personal preferences and subsequently administered standardized QoL questionnaires. A member of the chaplaincy or in-house volunteer organization visited the patient either daily or once every 2 days throughout the duration of their hospitalization. All patients completed questionnaires at baseline, at 2 weeks, and at 3 months. Each of the questionnaires was totaled, with higher scores representing positive response, except for one survey measure where lower scores represent improvement (QIDS-SR16). Twenty-three patients (n = 23, age 57 ± 11, 11 (48 %) male, 12 (52 %) female, mean duration of hospital stay 20 ± 15 days) completed the study. Total mean scores were assessed on admission, at 2 weeks and at 3 months. For all patients in the study, the mean QIDS-SR16 scores were 8.5 (n = 23, SD = 3.3) versus 6.3 (n = 18, SD = 3.5) versus 7.3 (n = 7, SD = 2.6). Mean FACIT-Sp-Ex (version 4) scores were 71.1 (n = 23, SD = 15.1) versus 74.7 (n = 18, SD = 20.9) versus 81.4 (n = 7, SD = 8.8). The mean MSAS scores were 2.0 (n = 21, SD = 0.6) versus 1.8 (n = 15, SD = 0.7) versus 2.5 (n = 4, SD = 0.7). Mean QoL Enjoyment and Satisfaction scores were 47.2 % (n = 23, SD = 15.0 %) versus 53.6 % (n = 18, SD = 16.4 %) versus 72.42 % (n = 7, SD = 22 %). The addition of spiritual counseling to standard medical management for patients with chronic heart failure patients appears to have a positive impact on QoL.

Left ventricular noncompaction cardiomyopathy: updated review.

The first case of noncompaction was described in 1932 after an autopsy performed on a newborn infant with aortic atresia/coronary-ventricular fistula. Isolated noncompaction cardiomyopathy was first described in 1984. A review on selected/relevant medical literature was conducted using Pubmed from 1984 to 2013 and the pathogenesis, clinical features, and management are discussed. Left ventricular noncompaction (LVNC) is a relatively rare congenital condition that results from arrest of the normal compaction process of the myocardium during fetal development. LVNC shows variability in its genetic pattern, pathophysiologic findings, and clinical presentations. The genetic heterogeneity, phenotypical overlap, and variety in clinical presentation raised the suspicion that LVNC might just be a morphological variant of other cardiomyopathies, but the American Heart Association classifies LVNC as a primary genetic cardiomyopathy. The familiar type is common and follows a X-linked, autosomal-dominant, or mitochondrial-inheritance pattern (in children). LVNC can occur in isolation or coexist with other cardiac and/or systemic anomalies. The clinical presentations are variable ranging from asymptomatic patients to patients who develop ventricular arrhythmias, thromboembolism, heart failure, and sudden cardiac death. Increased awareness over the last 25 years and improvements in technology have increased the identification of this illness and improved the clinical outcome and prognosis. LVNC is commonly diagnosed by echocardiography. Other useful diagnostic techniques for LVNC include cardiac magnetic resonance imaging, computerized tomography, and left ventriculography. Management is symptom based and patients with symptoms have a poorer prognosis. LVNC is a genetically heterogeneous disorder which can be associated with other anomalies. Making the correct diagnosis is important because of the possible associations and the need for long-term management and screening of living relatives.

Failing the failing heart: a review of palliative care in heart failure.

Heart failure (HF) is the most common reason for hospital admission for patients older than 65 years. With an aging population and improving survival in heart failure patients, the number of people living with HF continues to grow. As this population increases, the importance of treating symptoms of fatigue, dyspnea, pain, and depression that diminish the quality of life in HF patients becomes increasingly important. Palliative care has been shown to help alleviate these symptoms and improve patients' satisfaction with the care they receive. Despite this growing body of evidence, palliative care consultation remains underutilized and is not standard practice in the management of HF. With an emphasis on communication, symptom management, and coordinated care, palliative care provides an integrated approach to support patients and families with chronic illnesses. Early communication with patients and families regarding the unpredictable nature of HF and the increased risk of sudden cardiac death enables discussions around advanced care directives, health care proxies, and deactivation of permanent pacemakers or implantable cardioverter defibrillators. Cardiologists and primary care physicians who are comfortable initiating these discussions are encouraged to do so; however, many fear destroying hope and are uncertain how to discuss end-of-life issues. Thus, in order to facilitate these discussions and establish an appropriate relationship, we recommend that patients and families be introduced to a palliative care team at the earliest appropriate time after diagnosis.

Periprocedural adverse events in cell therapy trials in myocardial infarction and cardiomyopathy: a systematic review.

BACKGROUND: Cell therapy (CTh) is a promising novel therapy for myocardial infarction (MI) and ischemic cardiomyopathy (iCMP). Recognizing adverse events (AE) is important for safety evaluation, harm prevention and may aid in the design of future trials. OBJECTIVE: To define the prevalence of periprocedural AE in CTh trials in MI and iCMP. METHODS: A literature search was conducted using the MEDLINE database from January 1990 to October 2010. Controlled clinical trials that compared CTh with standard treatment in the setting of MI and/or iCMP were selected. AE related to CTh were analyzed. RESULTS: A total of 2,472 patients from 35 trials were included. There were 26 trials including 1,796 patients that used CTh in MI and 9 trials including 676 patients that used CTh in iCMP. Periprocedural arrhythmia monitoring protocols were heterogeneous and follow-up was short in most of the trials. In MI trials, the incidence of periprocedural adverse events (AE) related to intracoronary cell transplantation was 7.5 % (95 % CI 6.04-8.96 %). AE related to granulocyte colony-stimulating factor (GCS-F) used for cell mobilization for peripheral apheresis was 16 % (95 % CI 9.44-22.56 %). During intracoronary transplantation in iCMP, the incidence of periprocedural AE incidence was 2.6 % (95 % CI 0.53-4.67 %). There were no AE reported during transepicardial transplantation and AE were rare during transendocardial transplantation. CONCLUSIONS: The majority of periprocedural AE in CTh trials in MI occurred during intracoronary transplantation and GCS-F administration. In iCMP, periprocedural AE were uncommon. Avoiding intracoronary route for CTh implantation may decrease the burden of periprocedural AE. Standardization of AE definition in CTh trials is needed.

Transthoracic echocardiographic parameters in the estimation of pulmonary capillary wedge pressure in patients with present or previous heart failure.

Multiple echocardiographic criteria are routinely used for the estimation of left heart filling pressures. We assessed the predictive value of various echocardiographic parameters to estimate the left heart filling pressure and proposed a simplified approach for its evaluation. We collected the clinical, echocardiographic, and invasive hemodynamic data from 93 patients with heart failure who underwent right-sided heart catheterization and transthoracic echocardiography within a 24-hour period. Of these 93 patients, 57% had a left ventricular ejection fraction <50% and 69% had an elevated mean pulmonary capillary wedge pressure of ≥ 15 mm Hg. A mitral E/E' of ≥ 15 had a sensitivity of 55% but a specificity of 96%. A left atrial area of ≥ 20 cm(2) had a sensitivity of 66% and specificity of 89%. A deceleration time <140 ms had a sensitivity of 51% and specificity of 93% to predict a pulmonary capillary wedge pressure of ≥ 15 mm Hg. The combination of E/E' ≥ 15 ± left atrial area of ≥ 20 cm(2) ± deceleration time <140 ms provided a sensitivity of 92% and specificity of 85%. On multivariate analysis, the combination of E/E' ≥ 15, left atrial area of ≥ 20 cm(2), and deceleration time <140 ms was the most significant predictor of a pulmonary capillary wedge pressure of ≥ 15 mm Hg (odds ratio 48, 95% confidence interval 10 to 289, p <0.001). In conclusion, this simplified approach using 3 echocardiographic parameters provides an accurate and a practical approach for the routine estimation of the elevated left heart filling pressure.

Does the United States economy affect heart failure readmissions? A single metropolitan center analysis.

BACKGROUND: To determine the effects of the US economy on heart failure hospitalization rates. HYPOTHESIS: The recession was associated with worsening unemployment, loss of private insurance and prescription medication benefits, medication nonadherence, and ultimately increased rates of hospitalization for heart failure. METHODS: We compared hospitalization rates at a large, single, academic medical center from July 1, 2006 to February 28, 2007, a time of economic stability, and July 1, 2008 to February 28, 2009, a time of economic recession in the United States. RESULTS: Significantly fewer patients had private medical insurance during the economic recession than during the control period (36.5% vs 46%; P = 0.04). Despite this, there were no differences in the heart failure hospitalization or readmission rates, length of hospitalization, need for admission to an intensive care unit, in-hospital mortality, or use of guideline-recommended heart failure medications between the 2 study periods. CONCLUSIONS: We conclude that despite significant effects on medical insurance coverage, rates of heart failure hospitalization at our institution were not significantly affected by the recession. Additional large-scale population-based research is needed to better understand the effects of fluctuations in the US economy on heart failure hospitalization rates.

Predictors of re-hospitalization in patients with chronic heart failure.

Heart failure (HF) is a chronic, progressive illness that is highly prevalent in the United States and worldwide. This morbid illness carries a very poor prognosis, and leads to frequent hospitalizations. Repeat hospitalization in HF is both largely burdensome to the patient and the healthcare system, as it is one of the most costly medical diagnoses among Medicare recipients. For years, investigators have strived to determine methods to reduce hospitalization rates of HF patients. Despite such efforts, recent reports indicate that re-hospitalization rates remain persistently high, without any improvement over the past several years and thus, this topic clearly needs aggressive attention. We performed a key-word search of the literature for relevant citations. Published articles, limited to English abstracts indexed primarily in the PubMed database through the year 2011, were reviewed. This article discusses various clinical parameters, serum biomarkers, hemodynamic parameters, and psychosocial factors that have been reviewed in the literature as predictors of re-hospitalization of HF patients. With this information, our hope is that the future holds better risk-stratification models that will allow providers to identify high-risk patients, and better customize effective interventions according to the needs of each individual HF patient.

Pilot study of palliative care consultation in patients with advanced heart failure referred for cardiac transplantation.

BACKGROUND: Heart failure (HF) in its chronic form is an irreversible and progressive disease. Palliative care (PC) interventions have traditionally been focused on patients with advanced cancer. We performed a pilot study to assess the feasibility of implementing the American College of Cardiology/American Heart Association (ACC/AHA) guidelines for early PC intervention in patients with advanced HF who were seeking or received potentially curative therapies. METHODS: Twenty consecutive patients with advanced HF referred to PC from the heart transplant service with stage D, New York Heart Association (NYHA) class III-IV symptoms were analyzed retrospectively in a tertiary care setting. Data were reviewed to assess the clinical impact of PC intervention. Feedback was obtained to assess satisfaction of the patients, their families, and the health care professionals. An independent assessment of the impact of the PC service in the care of each patient was performed by a cardiologist and PC physician by use of a scoring system. RESULTS: Twenty consecutive patients with HF were analyzed. PC consult was obtained for a variety of reasons. All patients complained of a high symptom burden. PC consultation resulted in a decrease in the use of opioids and increased patient satisfaction. Patients and their family members generally reported improved holistic care, continuity of care, more focused goals of care, and improved planning of treatment courses. The nonstandardized scoring system used to determine the impact of the PC service showed an average of moderate to significant impact when assessed by both a cardiologist and a PC physician. CONCLUSION: PC consultation appears to be beneficial in the treatment and quality of life of advanced HF patients, independent of their prognosis. This pilot study demonstrated feasibility and sufficient evidence of clinical benefit to warrant a larger randomized clinical trial assessing the benefit of standard involvement by PC in patients with advanced HF, independent of the patient's prognosis or treatment goals.

The potential effects of IGF-1 and GH on patients with chronic heart failure.

Heart failure (HF) is an important health concern with almost a quarter million deaths each year despite advances in medical therapy. Improvement of cardiac function has been shown to reduce morbidity and mortality in patients with HF. There has been recent interest in the growth hormone (GH) / insulin-like growth factor (IGF) pathway as a potential therapeutic target for patients with HF. Insulin-like growth factor 1 has been shown to augment cardiac function ex vivo and in animals. It was hypothesized that IGF-1/IGF-binding protein 3 levels might be able to provide prognostic benefits in patients with heart disease. Initial observational studies have shown significant benefits from GH supplementation including improved ejection fraction, increased exercise tolerance, and decreased New York Heart Association functional class. These results, however, were not replicated in randomized, controlled trials. Patients with advanced stages of HF might develop cachexia associated with a state of significant GH resistance. The lack of response to GH supplementation may be secondary to a deficiency in IGF-1, the effector hormone. Hypothetically, this group of patients could benefit from direct IGF-1 supplementation. Combined therapy with GH and IGF-1 is appealing; however, future trials in patients with advanced HF are warranted to prove this concept.

The effects of spirituality and religion on outcomes in patients with chronic heart failure.

Heart failure (HF) is a chronic progressive disease with marked morbidity and mortality. Patients enduring this condition suffer from fluctuations in symptom burden such as fatigue, shortness of breath, chest pain, sexual dysfunction, dramatic changes in body image and depression. As physicians, we often ask patients to trust in our ability to ameliorate their symptoms, but oftentimes we do not hold all of the answers, and our best efforts are only modestly effective. The suffering endured by these individuals and their families may even call into question one's faith in a higher power and portends to significant spiritual struggle. In the face of incurable and chronic physical conditions, it seems logical that patients would seek alternative or ancillary methods, notably spiritual ones, to improve their ability to deal with their condition. Although difficult to study, spirituality has been evaluated and deemed to have a beneficial effect on multiple measures including global quality of life, depression and medical compliance in the treatment of patients with HF. The model of HF treatment incorporates a multidisciplinary approach. This should involve coordination between primary care, cardiology, palliative care, nursing, patients and, importantly, individuals providing psychosocial as well as spiritual support. This review intends to outline the current understanding and necessity of spirituality's influence on those suffering from HF.

The dilemma, causes and approaches to avoid recurrent hospital readmissions for patients with chronic heart failure.

Heart failure is a progressive illness that carries significant morbidity and mortality. This highly prevalent illness leads to frequent, costly hospitalizations with approximately 50% of patients being readmitted within 6 months of initial hospitalization. While rehospitalization has been extensively studied in the past, little progress has been made in terms of reducing readmission rates of heart failure patients in the last decade despite increasing costs with impending resource limitations. We discuss disease-centered, physician-centered, and patient-centered factors that lead to rehospitalization as well as community/resource availability factors that contribute to rehospitalization of patients suffering from chronic heart failure. In addition, predictors of hospitalization and interventions that reduce hospitalization will be critically evaluated. With a complete understanding of heart failure rehospitalization, we hope the future holds more effective ways to prevent heart failure progression and thus rehospitalization, improved risk-stratification models to identify patients high-risk for rehospitalization, and sustained interventions that are customized according to the etiology of the clinical decline of heart failure patients that ultimately results in frequent rehospitalizations.

Left ventricular assist device as 'bridge to weight loss' prior to transplantation in obese patients with advanced heart failure.

BACKGROUND: Obesity is a risk factor for heart failure (HF) and associated with poor outcomes after cardiac transplantation. We assessed change in total body weight, morbidity and mortality in obese heart failure patients after implantation of a left ventricular assist device (LVAD) compared to medical management. MATERIAL/METHODS: Nineteen patients (9 females, age 51.3 ± 10 years) with a body mass index (BMI) ≥ 30.0 kg/m² and advanced HF (NYHA class III-IV, stage D) were evaluated. Thirteen (group 1) received insertion of a LVAD as bridge to transplantation. The remaining patients (group 2) were medically managed. All were advised on lifestyle modification. RESULTS: At baseline, group 1 (49.1 ± 10.7 years) had a total body weight (BW) of 246.6 ± 34.9 pounds (mean ± SD) and a BMI of 36.1 ± 4 kg/m². Group 2 (56 ± 6.7 yrs) had a BW of 238.8 ± 73.6 pounds and a BMI of 39.1 ± 9.3 kg/m2 (n.s. compared to group 1). All patients were alive at 12 months. At 6 months, BW in group 1 was reduced to 216.3 ± 20.8 pounds, and BMI to 31.8 ± 3.3 kg/m² (p < 0.05). At 6 months, BW in group 2 was 238.2 ± 84.6 pounds, and BMI was 39.1 ± 11.6 kg/m² (n.s. vs. baseline, p < 0.05 compared to group 1). The decrease in BW in group 1 was 12.3 ± 12% (30.3 ± 28.5 pounds). There was no change in BW in group 2 (0.3 ± 8.7%, 0.6 ± 21 pounds, p < 0.05 vs. group 1). At 12 months, 7 patients in group 1 (54%) underwent cardiac transplantation. CONCLUSIONS: LVAD insertion resulted in weight loss in obese patients not considered for heart transplantation compared to medically managed patients.

Is vitamin D deficiency associated with heart failure? A review of current evidence.

An estimated 1 billion people worldwide have deficient or insufficient levels of vitamin D. Even more alarming is the association of vitamin D deficiency with many types of diseases, particularly heart failure (HF). Hypovitaminosis D has been observed to be highly prevalent in the HF community with rates varying from approximately 80% to 95%. Higher rates of deficiency have been linked to winter months, in patients with protracted decompensated HF, darker skin pigmentation, and higher New York Heart Association (NYHA) classes. In fact, some data suggest vitamin D deficiency may even be an independent predictor of mortality in patients with HF. Traditionally obtained through UV exposure and activated in the liver and then the kidneys, vitamin D is classified as a vitamin but functions as a steroid hormone. The hormone acts through the vitamin D receptor (VDR), which is expressed in vascular smooth muscle cells, renal juxtaglomerular cells, and most interestingly, cardiac myocytes. Studies have shown that the association between vitamin D deficiency and HF often manifests in the structural components of cardiac myocytes and/or through alterations of the neurohormonal cascade. In addition, vitamin D may also act rapidly through intracellular nongenomic receptors that alter cardiac contractility. Unfortunately, prospective vitamin D supplementation trials show mixed results. In rat models, successful correction of deficiency was associated with reductions in ventricular hypertrophy. In humans, however, echocardiographic dimensions did not change significantly. These results bring into questions whether vitamin D is a risk factor for HF, a marker of HF disease severity, or has a true pathologic role. This article provides a thorough review of vitamin D deficiency etiology, prevalence, and possible pathophysiologic role in HF. Furthermore, we carefully review prospective trials on vitamin D therapy in HF. We believe more trials on vitamin D therapy in HF need to be conducted before any conclusions can be drawn.

Philosophical implications of the systemic and patient-oriented management of chronic heart failure.

Chronic heart failure is a lifelong disease that involves a large variety of symptoms and, ultimately, the entire organism relatively early in the disease process. At least in part, this is in contrast to other chronic conditions such as diabetes, renal failure or cancer. Modern treatment of patients with chronic heart failure goes beyond the mere prescription of vasodilators or inotropes. The multitude of multi-organ involvements and associated symptoms unrelated to pure cardiac contractile failure, as well as the psychosocial burden for patients and their direct environment, calls for a re-engagement with the philosophical aspects of medical care. Such a process may well challenge the approach commonly taken by health care providers. We further suggest a broader and more holistic view of medical care--in this case in regard to heart failure--and one that is based on patients' and physicians' understanding of health and disease, autonomy, suffering, existential values and expectations that might positively affect treatment strategies and outcomes.

Andropause and the development of cardiovascular disease presentation-more than an epi-phenomenon.

Andropause refers to a generalized decline of male hormones, including testosterone and dehydroepiandrosterone in middle-aged and aging men. This decline in hormones has been associated with changes such as depression, loss of libido, sexual dysfunction, and changes in body composition. Aging has been associated with an abundance of concomitant diseases, in particular cardiovascular diseases, and although andropause is correlated to aging, a causal relationship between reduction of androgens and the development of chronic diseases such as atherosclerosis and heart failure has not been convincingly established yet. On the other hand, increasing data has emerged that revealed the effects of low levels of androgens on cardiovascular disease progression. As an example, low levels of testosterone have been linked to a higher incidence of coronary artery disease. Whether hormone replacement therapy that is used for andropausal men to alleviate symptoms of "male menopause" can halt progression of cardiovascular disease, remains controversially discussed, primarily due to the lack of well-designed, randomized controlled trials. At least for symptom improvement, the use of androgen replacement therapy in andropausal men may be clinically indicated, and with the appropriate supervision and follow up may prove to be beneficial with regard to preservation of the integrity of cardiovascular health at higher ages.

Andropause and the development of cardiovascular disease presentation more than an epi-phenomenon / 老年心脏病学杂志（英文版）

Andropause refers to a generalized decline of male hormones, including testosterone and dehydroepiandrosterone in middle-aged and aging men. This decline in hormones has been associated with changes such as depression, loss of libido, sexual dysfunction, and changes in body composition. Aging has been associated with an abundance of concomitant diseases, in particular cardiovascular diseases, and although andropause is correlated to aging, a causal relationship between reduction of androgens and the development of chronic diseases such as atherosclerosis and heart failure has not been convincingly established yet. On the other hand, increasing data has emerged that revealed the effects of low levels of androgens on cardiovascular disease progression. As an example, low levels of testosterone have been linked to a higher incidence of coronary artery disease. Whether hormone replacement therapy that is used for andropausal men to alleviate symptoms of male menopausecan halt progression of cardiovascular disease, remains controversially discussed, primarily due to the lack of well-designed, randomized controlled trials. At least for symptom improvement, the use of androgen replacement therapy in andropausal men may be clinically indicated, and with the appropriate supervision and follow up may prove to be beneficial with regard to preservation of the integrity of cardiovascular health at higher ages.

Heart transplantation in the elderly: why cardiac transplantation does not need to be limited to younger patients but can be safely performed in patients above 65 years of age.

Within the last forty years, heart transplantation as the ultimate option for the treatment of end-stage heart disease has undergone dramatic changes and advances in operative techniques, postoperative care, immunosuppression, and rejection management which resulted in reduced morbidity and mortality. As the heart failure epidemic worsens and the population grows older, cardiac transplantation criteria have expanded for end-stage heart disease refractory to medical management. Although outcomes after cardiac transplantation have improved, the critical organ shortage is a limitation to its efficacy. The demand-supply disparity for heart transplantations has led to clinical and ethical issues examining adequate candidacy for organ transplantation. Cardiac transplantation in the elderly recipient was considered a contraindication due to poor survival rates compared to younger recipients. Given the increase in life expectancy over the last decades, single-center studies have assessed the outcome of transplantation among elderly recipients and comparable survival and quality of life have been described among older heart transplantation recipients. Alternatives to cardiac transplantation which have become more common, such as mechanical circulatory support, and further investigation of the viability of transplantation in the elderly may help determine the proper allocation of the limited organ supply.

Erectile dysfunction as a complication of heart failure.

Erectile dysfunction (ED) is an increasingly common problem in the aging population and has been associated with chronic heart failure (HF), either as an epiphenomenon or even as an early marker for underlying cardiovascular disease. ED has a significant effect on patients' quality of life. This chapter reviews ED in patients with HF and prevention and treatment based on current data from the literature. Causes include physiologic changes resulting in decreased cardiac function and exercise capacity, intrinsic vascular and neurohormonal abnormalities, and extrinsic factors such as medication side effects and psychological issues. Physicians should address these issues with patients and begin treatment by optimizing HF management and minimizing medications with ED side effects. Use of phosphodiesterase-5 inhibitors provides significant improvement of ED and quality of life. Further research still is needed regarding long-term effects of ED treatment, investigation of newer medications, and preventive measures in this patient population.

Persistent sexual dysfunction impairs quality of life after cardiac transplantation.

INTRODUCTION: The impact of sexual dysfunction (SD) on mental and physical health after heart transplantation (HTx) has not been established. AIM: We investigated the relationship of SD on quality of life (QoL), physical and mental health, and depressive symptoms after HTx. MAIN OUTCOME MEASURES: We evaluated SD according to the International Index of Erectile Dysfunction and the Female Sexual Function Index. QoL, physical and mental health were assessed using: 1) Short Form 12 Health Survey Questionnaire, 2) Quality of Life Enjoyment and Satisfaction Questionnaire--Short Form, and two depressive symptoms questionnaires: 1) Beck Depression Inventory-II and 2) Quick Inventory Depressive Symptomatology-Self Report. METHODS: We enrolled patients who were greater than 6 months post HTx. Patients unable to read English, had pelvic surgery or trauma, urogenital abnormalities, or sexually inactive were excluded. RESULTS: Out of 79 subjects that were screened, 33 men and 6 women participated (mean age 61.4 + 1.4). Response rates were at least 82% for all questionnaires. Overall prevalence of SD was 61%, with 78% of men being affected and 50% of women. There was no significant difference in measures between genders. HTx recipients with SD reported significantly worse QoL on measures of physical health when compared to those without SD. After HTx, patients suffering from SD had significantly worse general health (P = 0.02) and physical health (P = 0.02), including physical functioning (P = 0.01) and physical role limitation (P = 0.01). In contrast, mental health and depressive symptoms after HTx were not significantly different between those with and without SD. CONCLUSIONS: After HTx a high prevalence of SD remains among both men and women. Patients with SD had worse general and physical health but not depressive symptoms when compared to those without SD. The contributing factors may be more related to physical rather than psychological causes.

Growth hormone and testosterone in heart failure therapy.

IMPORTANCE OF THE FIELD: Heart failure is a progressive disease affecting millions of people worldwide. The disease carries a significantly high morbidity and mortality risk. There are multiple pharmaceutical options to decrease this risk and prolong survival; however, despite optimization of medical management, several patients still await heart transplant, the only definitive cure for heart failure. To slow the progression of disease preventing need for transplantation, improve clinical symptoms, and improve heart failure outcomes, there is a persistent need to discover new therapeutic strategies. Of interest, low growth hormone and testosterone levels have been associated with a worsening degree of heart failure. Many studies have begun to show a clinical improvement in heart failure symptoms when these levels are corrected with hormonal therapy. These findings, although mixed, are promising and indicate that both testosterone and growth hormone therapy should be considered as adjunctive therapy in advanced heart failure patients. AREAS COVERED IN THIS REVIEW: This review discusses the physiology of both of these natural hormones, their therapeutic effects in heart failure and data from the published literature on studies using growth hormone or testosterone in patients with chronic heart failure. An extensive search of PubMed was conducted for topics on heart failure, growth hormone, insulin-like growth factor, testosterone, their physiology and pathophysiology, and trials in which they have been used as therapeutic interventions between 1989 and 2009. WHAT THE READER WILL GAIN: The reader will gain an understanding of the intricate balance of both of these hormones in the disease state of heart failure. In addition, the trials conducted using these hormones in pharmacotherapy for heart failure are discussed along with proposed theories for interstudy variability. TAKE HOME MESSAGE: Testosterone deficiency and growth hormone resistance are positively associated with a poor state of heart failure. Treatment of deficiency improves outcomes in heart failure; however, there is a significant paucity of data with regard to testosterone and heart failure as well as a significant amount of study variability with growth hormone and heart failure.