Renal hemodynamics in heart failure: implications for treatment.

PURPOSE OF REVIEW: The purpose of this review is to describe the hemodynamic alterations in the kidney which occur in heart failure and to understand the cardiovascular and renal mechanisms responsible for these alterations. Implications for the clinical management of heart failure will be delineated on the basis of the pathophysiologic cardiorenal interactions. RECENT FINDINGS: Recent studies have shown that patients with heart failure exhibit abnormal cardiorenal hemodynamics on the basis of numerous pathophysiologic disturbances involving both the cardiovascular and renal systems. Macrovascular stiffening leads to microvascular damage with impairment of renal autoregulation. Diffuse neurohormonal activation occurs of multiple systems, particularly the renin-angiotensin-aldosterone system, sympathetic nervous system, arginine vasopressin system, endothelin system, and natriuretic peptide system, leading to an overall vasoconstrictive state promoting sodium and water retention and further impairment of cardiac function. Pharmacologic therapy directed at specific biochemical targets within these neurohormonal pathways has shown marked benefits in improving both the symptoms of heart failure and clinical outcomes. SUMMARY: Heart failure is characterized by abnormal cardiovascular hemodynamics, sodium and fluid retention, and diffuse neurohormonal activation, all of which affect the net renal hemodynamic state. An understanding of the pathophysiologic mechanisms is necessary to optimally manage patients with heart failure and help restore cardiorenal homeostasis.

Radial versus femoral access for rescue percutaneous coronary intervention with adjuvant glycoprotein IIb/IIIa inhibitor use.

BACKGROUND: The transradial approach has not been evaluated for "rescue" percutaneous coronary intervention (PCI) with glycoprotein (GP) IIb/IIIa inhibitor following failed thrombolysis. OBJECTIVES: To compare the safety and procedural outcomes of the transradial and transfemoral approaches to rescue PCI. METHODS: Rescue PCI cases with adjuvant GP IIb/IIIa inhibitor performed at two centres were reviewed retrospectively, and the bleeding rates, equipment use and procedure times for the femoral and the radial approach were compared. RESULTS: Radial access was attempted in 47 of 111 cases (42%) and crossover to femoral access was required in two cases (4%). Major bleeding occurred in three patients in the radial group (6%) and in 12 patients in the femoral group (19%; P=0.06). Radial access was associated with less access site-related major bleeding (0% versus 9%; P=0.04) and fewer transfusions (4% versus 19%; P=0.02). After excluding patients with intra-aortic balloon pump, this difference was no longer statistically significant (4% versus 8%; P=0.7). Fluoroscopy times and contrast use were similar, and the time to first balloon inflation was slightly longer with radial access (33 min versus 30 min; P=0.07). CONCLUSIONS: In selected patients, the transradial approach for rescue PCI is safe and effective. The present findings warrant further study in a prospective, randomized trial.