digitoxin and Ventricular-Dysfunction--Left

To determine patterns of medication use based on clinical variables in patients with heart failure, we analyzed data from 5,999 patients participating in the Registry of Studies of Left Ventricular Dysfunction (SOLVD). The Registry comprised a broad spectrum of patients with heart failure, including some with predominantly diastolic dysfunction. Drug use was determined in a population cross-sectional manner at the time of identification (74% hospitalized). The median number of drugs per patient was four, with diuretics taken by 62%, digitalis by 45%, angiotensin-converting enzyme inhibitors (ACE-I) by 32%, calcium channel blockers by 36%, antiarrhythmics by 22%, and beta-blockers by 18%. Only 18% were on the combination of ACE-I, diuretic, and digitalis. Stratification for diagnosis, heart failure symptoms, and ejection fractions demonstrated that triple-drug therapy (digitalis, diuretic, and ACE-I) was common only in those with ejection fractions less than .20 and several signs or symptoms of heart failure. Older patients were taking diuretics frequently (73% of patients older than 70 years of age), and our European center used fewer drugs overall, while prescribing digitalis about half as frequently as North American clinics. These data serve as the baseline for analysis of evolving therapeutic practice in patients with heart failure.

Topics: Aged; Belgium; Calcium Channel Blockers; Canada; Cross-Sectional Studies; Digitalis; Diuretics; Double-Blind Method; Drug Therapy, Combination; Drug Utilization Review; Female; Heart Failure; Humans; Male; Middle Aged; Multicenter Studies as Topic; Peptidyl-Dipeptidase A; Plants, Medicinal; Plants, Toxic; Practice Patterns, Physicians'; Randomized Controlled Trials as Topic; Registries; Stroke Volume; United States; Ventricular Dysfunction, Left

Outcome is better in patients with idiopathic dilated cardiomyopathy (IDC) than in ischemic heart failure (HF), but morbidity and mortality are nevertheless presumed to be substantial. Most data on the prognosis in IDC stem from research performed before the widespread use of current evidence-based treatment, including implantable devices. We report outcome data from a cohort of patients with IDC treated according to current HF guidelines and compare our results with previous figures: 102 consecutive patients referred to our tertiary care hospital with idiopathic IDC and a left ventricular ejection fraction <40% were included in a prospective cohort study. After extensive baseline work-up, follow-up was performed after 6 and 13 months. Vital status and heart transplantation were recorded. Over the first year of follow-up, the patients were on optimal pharmacological treatment, and 24 patients received implantable devices. Left ventricular ejection fraction increased from 26 ± 10% to 41 ± 11%, peak oxygen consumption increased from 19.5 ± 7.1 to 23.4 ± 7.8 ml/kg/min, and functional class improved substantially (all p values <0.001). After a median follow-up of 3.6 years, 4 patients were dead, and heart transplantation had been performed in 9 patients. According to our literature search, survival in patients with IDC has improved substantially over the last decades. In conclusion, patients with IDC have a better outcome than previously reported when treated according to current guidelines.

Topics: Adrenergic beta-Antagonists; Adult; Aged; Angiotensin Receptor Antagonists; Angiotensin-Converting Enzyme Inhibitors; Cardiac Resynchronization Therapy; Cardiomyopathy, Dilated; Cardiotonic Agents; Cohort Studies; Death, Sudden, Cardiac; Defibrillators, Implantable; Digitoxin; Digoxin; Diuretics; Exercise Test; Female; Heart Transplantation; Humans; Male; Middle Aged; Mineralocorticoid Receptor Antagonists; Oxygen Consumption; Prospective Studies; Stroke Volume; Treatment Outcome; Ventricular Dysfunction, Left

A 50-year-old man received an orthotopic heart transplant because of severe coronary heart disease and congestive heart failure. Two years after the transplantation, a continuous murmur occurred at the left sternal edge after repeated endomyocardial biopsies. Echocardiography and coronary angiography revealed a dilated left anterior descending artery with a fistula to the right ventricle. The circumflex was large with an equally postero-lateral branch, and the right coronary artery was rather small with collaterals to the distal part of the left anterior descending branch. The patient had refused any intervention to close the fistula. The left ventricular levogram was normal. Two years later, in a follow-up angiogram, the left ventricular ejection fraction had decreased as a result of hypo- and akinesis of the apex and posterior wall. We suggest that this local wall motion disturbance derives from a steal phenomenon rather than being a sequela of rejection. The decrease in left ventricular ejection fraction was associated with shortness of breath upon moderate exercise. Standard heart failure medication relieved the patient's symptoms. The observation of local wall motion disturbances in this case, as well as conflicting views in the literature, raises the question whether postbiopsy coronary fistulas in transplant patients should be closed.

Topics: Angiotensin-Converting Enzyme Inhibitors; Cardiac Catheterization; Coronary Angiography; Coronary Disease; Digitalis; Echocardiography; Follow-Up Studies; Heart Failure; Heart Transplantation; Heart Ventricles; Humans; Male; Middle Aged; Phytotherapy; Plants, Medicinal; Plants, Toxic; Postoperative Complications; Vascular Fistula; Ventricular Dysfunction, Left; Ventricular Function, Right