Prescription patterns of diuretics in chronic heart failure: a contemporary background as a clue to their role in treatment.

Background: Diuretics are the cornerstone of treatment for the congestive symptoms of heart failure (HF). Despite their widespread use, diuretic prescription data in clinical practice are scarce. In this study we evaluated the prescription pattern of diuretics in a large population of HF outpatients, enrolled by a national network of hospital-based cardiologists.

Serum levels of carbohydrate antigen 125 in patients with chronic heart failure: relation to clinical severity, hemodynamic and Doppler echocardiographic abnormalities, and short-term prognosis.

Objectives: The aim of this study was to evaluate the serum levels of carbohydrate antigen 125 (CA125) in patients with congestive heart failure (CHF).

Background: CA125 is a glycoprotein produced by serosal epithelium, found to be increased in ovarian cancer.

Methods: Serum levels of CA125 were obtained in 286 patients (122 males and 164 females; age 69 +/- 13 years) with CHF (left ventricular ejection fraction 30 +/- 11%).

Absence of inferior vena cava as a rare cause of deep venous thrombosis complicated by liver and lung embolism.

Congenital anomalies of the inferior vena cava such as absence or atresia are uncommon vascular defects and result from aberrant development during embryogenesis. We report a case of a young female patient affected by proximal deep venous thrombosis (DVT) complicated by liver and pulmonary embolism; subsequent extensive evaluation revealed the congenital absence of infrarenal inferior vena cava, with emboli probably occurring through collateral veins. Accordingly, in young patients with idiopathic DVT of the lower extremities and pelvic veins, the presence of inferior vena cava abnormalities should always be considered and investigated, together with classic coagulation factors, as a factor predisposing to thromboembolic complications.

Symptomatic aortic stenosis: does systemic hypertension play an additional role?

Hypertension and aortic stenosis represent 2 different models of left ventricular systolic overload. Previous studies have observed different remodeling patterns in these conditions. There is, however, little information about patients with coexisting aortic stenosis and hypertension.

[Finally a highly specific test for the differential diagnosis of dyspnea: BNP determination].

A simple blood test useful to the diagnosis and follow-up of congestive heart failure would have a favorable impact on the management of a large populations of patients. Several recent studies have demonstrated that blood levels of Brain Natriuretic Peptide (BNP) may be useful for differentiating heart failure from lung disease in patients presenting to emergency department with dyspnea. Furthermore, BNP might serve as screening test for left ventricular dysfunction (systolic and diastolic), correlates with severity of congestive heart failure and is an independent predictor of outcome.

Clinical features and prognosis associated with a preserved left ventricular systolic function in a large cohort of congestive heart failure outpatients managed by cardiologists. Data from the Italian Network on Congestive Heart Failure.

Background: The aim of this study was to evaluate the clinical characteristics, 1-year prognosis and therapeutic approach of heart failure with a preserved left ventricular systolic function in a large multicenter registry of patients referred to specialized heart failure clinics.

Methods: The study population consisted of 5164 outpatients (mean age 62 +/- 12 years, 78.8% male, 28.

Reliability of new and old Doppler echocardiographic indexes of the severity of aortic stenosis in patients with a low cardiac output.

Background: In addition to the conventional "flow-corrected" parameters (continuity equation and aortic valve resistance), new and simpler Doppler echocardiographic indexes of the severity of aortic stenosis have recently been introduced. These measures can be classified as "function-corrected" indexes (fractional shortening-velocity ratio and ejection fraction-velocity ratio) and "pressure-corrected" indexes (percent stroke work loss). Little information however is available about the diagnostic accuracy of each of these parameters in identifying patients with severe aortic stenosis in low-flow states, in which the diagnosis and clinical decision-making are more difficult and challenging.

[Recurrent episodes of acute non-cardiogenic pulmonary edema caused by ingesting hydrochlorothiazide].

We describe a case of a patient presenting repeated episodes of sudden-onset pulmonary edema each occurring immediately after the ingestion of hydrochlorothiazide. The close temporal relationship between the ingestion of hydrochlorothiazide and the onset of symptoms together with the rapid and full clinical recovery after the interruption of therapy, allowed the diagnosis of drug-induced pulmonary edema and a possible anaphylactoid hypotension. The initially low white blood cell count, associated with hemoconcentration, and the increase in white blood cells during the following 24 hours, is consistent with the hypothesis of intrapulmonary sequestration of granulocytes causing pulmonary edema.

Mechanisms and immediate outcome of in-hospital cardiac arrest in patients with advanced heart failure secondary to ischemic or idiopathic dilated cardiomyopathy.

To differentiate patients with congestive heart failure who are more prone to develop malignant ventricular tachyarrhythmias or severe bradyarrhythmias as the terminal event, we retrospectively evaluated a group of 48 patients with advanced heart failure who experienced a monitored cardiac arrest during hospital stay. We found no significant differences with respect to several variables, apart from clinical status, which was worse in patients whose cardiac arrest was precipitated by severe bradycardia or electromechanical dissociation.

Prevalence of isolated left ventricular diastolic dysfunction in hypertension as assessed by combined transmitral and pulmonary vein flow Doppler study.

In a relatively large population of patients with treated systemic hypertension and normal left ventricular systolic function, prevalence of abnormalities of left ventricular diastolic function, as assessed by Doppler echocardiographic study of mitral and pulmonary vein flow, was high, with 51% of patients showing indirect signs of increased left ventricular end-diastolic pressure. Furthermore, our data documented that a "normal" mitral flow profile does not exclude the presence of an abnormality of left ventricular filling, which could be otherwise identified by combined analysis of a pulmonary vein flow profile.

Relative contribution of resting haemodynamic profile and lung function to exercise tolerance in male patients with chronic heart failure.

Objective: To clarify the relative contribution of resting haemodynamic profile and pulmonary function to exercise capacity in patients with heart failure.

Setting: Cardiology department and cardiac rehabilitation unit in a tertiary centre.

Design: 161 male patients (mean (SD) age 59 (9) years) with heart failure (New York Heart Association class II-IV, left ventricular ejection fraction 23 (7)%) underwent spirometry, alveolar capillary diffusing capacity (DLCO), and mouth inspiratory and expiratory pressures (MIP, MEP, respectively, in 100 patients).

[Is a totally non-invasive assessment of the hemodynamic profile possible in patients with chronic heart failure?].

Relevant hemodynamic information can be obtained by a comprehensive Doppler echocardiographic examination in patients with various cardiac diseases. The assessment of left heart hemodynamics by Doppler echocardiography has been addressed by several investigators. The feasibility and the accuracy of methods for the estimation of left ventricular filling pressure and cardiac output have been validated by comparative right heart catheterization.

[Functional mitral insufficiency].

The term "functional mitral regurgitation" is generally used to indicate the presence of mitral regurgitation in patients with left ventricular systolic dysfunction in the absence of structural abnormalities of mitral leaflets and chordal or papillary muscle rupture. Functional mitral regurgitation is commonly found in heart failure, and its presence and severity seem to contribute to exercise intolerance and poor prognosis observed in heart failure patients. Several pathogenetic mechanisms have been proposed to explain the pathophysiology of functional mitral regurgitation, in particular a) mitral annular dilation, b) geometric changes in the left ventricle from a typical ellipsoidal shape to a more spherical shape, with apical and outward displacement of papillary muscles and restriction of valve motion ("leaflet tethering hypothesis"), and c) reduction of closing force of the mitral valve ("leaflet closing force hypothesis"), as a consequence of a lower difference between left ventricular systolic pressure (reduced from left ventricular dysfunction) and left atrial pressure (increased).

[Heart failure with conserved systolic function. Therapeutic potential with beta blocking agents].

It is increasingly recognized that the syndrome of congestive heart failure may occur in the absence of any abnormality of left ventricular systolic function. In this situation, the clinical picture of heart failure, particularly the presence of symptoms and/or signs of pulmonary congestion, is usually considered a consequence of an abnormal diastolic function of the left ventricle (diastolic heart failure). However, in the individual patient, several other potential causes should be taken into account before attributing to an isolated diastolic dysfunction of the left ventricle the pathogenetic role of clinical presentation.

Pulmonary artery hypertension in adult patients with symptomatic valvular aortic stenosis.

Pulmonary hypertension (PH) has been reported in patients with valvular aortic stenosis (AS) and has been found to be associated with a more severe clinical picture and a poor prognosis after aortic valve replacement. The aim of this study was to assess the prevalence of PH in adult patients with symptomatic AS undergoing cardiac catheterization, and to evaluate the relation between pulmonary artery (PA) systolic pressure and hemodynamic and clinical variables to further clarify the pathogenetic mechanisms. We assessed right-sided heart hemodynamics during cardiac catheterization in 388 patients with symptomatic isolated or predominant AS.

Doppler echocardiographic assessment of hemodynamic progression of valvular aortic stenosis over time: comparison between aortic valve resistance and valve area.

Background: Doppler-derived aortic valve resistance (AVR), i.e. the ratio between pressure gradient and flow rate, has been proposed as an alternative parameter to valve area (AVA) for assessing the hemodynamic severity of aortic stenosis (AS).

Use of cardiopulmonary exercise testing with hemodynamic monitoring in the prognostic assessment of ambulatory patients with chronic heart failure.

Objectives: We studied whether direct assessment of the hemodynamic response to exercise could improve the prognostic evaluation of patients with heart failure (HF) and identify those in whom the main cause of the reduced functional capacity is related to extracardiac factors.

Background: Peak exercise oxygen consumption (VO2) is one of the main prognostic variables in patients with HF, but it is influenced also by many extracardiac factors.

Methods: Bicycle cardiopulmonary exercise testing with hemodynamic monitoring was performed, in addition to clinical evaluation and radionuclide ventriculography, in 219 consecutive patients with chronic HF (left ventricular ejection fraction, 22 +/- 7%; peak VO2, 14.

Dobutamine-induced changes in pulmonary artery pressure in patients with congestive heart failure and their relation to abnormalities of lung diffusing capacity.

Short-term infusion of dobutamine may determine a mild, statistically significant increase in pulmonary artery pressure from baseline in 30% of patients with moderate to severe heart failure despite systemic effects (changes in cardiac index and systemic vascular resistance) similar to those observed in patients showing a large reduction in right heart pressures. The increase in pulmonary artery pressure observed seems to be associated with a lower pulmonary diffusing capacity, probably reflecting a reduction in recruitment and distension capacity of pulmonary circulation.

Effects of maximally tolerated oral therapy on the six-minute walking test in patients with chronic congestive heart failure secondary to either ischemic or idiopathic dilated cardiomyopathy.

In patients with heart failure, therapy with "maximally tolerated" oral doses of diuretics, vasodilators, and digitalis results in a significant increase in the distance walked during the 6-minute walking test, compared with conventional therapy at "standard" doses, indicating an improvement in exercise tolerance. The 6-minute walk test is a simple, inexpensive, and well-tolerated test to measure changes in exercise tolerance induced by pharmacologic interventions, even on a short-term basis.