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Efficacy and safety of enhanced external counterpulsation in mild to moderate heart failure: A preliminary report
The Third Annual Scientific Meeting
•
HFSA
53
192
193
Prescription Patterns for Congestive Heart Failure in an Asian University Hospital Bernard W.K. Kwok, Tiong-Cheng Yeo, Boon-Lock Chia; Cardiac Department, National University Hospital, Singapore
Hemodynamic Profile of Patients with Severe Heart Failure by Impedance Cardiography Hector O. Ventura, Sherry J. Augustine, Yvonne B. Greenlee, Ibraiz Iqbal, Dwight D. Stapleton, Frank W. Smart; Tulane University Medical Center, New Orleans, LA
Recent studies have documented beneficial effects of beta-blockers, ACE-inhibitors and digoxin in patients with heart failure. To determine the prescription patterns in such patients, we did a retrospective analysis of all hospital admissions for congestive heart failure (ICD-9 Code 4280) in 1998. Of 635 admissions, 225 patients with LVEF -< 40% were identified (56% males, mean age 68 -- 25 years, range 36 to 98 years). The average hospital stay was 6 22 10 days. Aefiologies for heart failure were ischemic heart disease (77%), idiopathic dilated cardiomyopathy (16%), valvular heart disease (4%) and hypertensive heart disease (3%). Mean LVEF was 25 22 16 %. The prescription usage of the following drugs are:
ACE-inhibitors / Angiotensin-II antagonists diuretics nitrates hydrailazine digoxin beta-blockers spironolactone
81% 94% 72% 8% 64% 5% 5%
Despite recent literature documenting the beneficial effects of beta~blockers in congestive heart failure, we find that this class of drugs is under-prescribed. This perhaps reflects the reluctance or fear amongst physicians to embrace new knowledge, especially one that seems counterintuitive. In addition, we find that the commonest prescribed di'ug in each class was the lower cost generic ones. Captopril accounted for 69% of all ACE-inhibitors prescribed, while frusemide was the diuretic agent used in 90%. Generic dinitrate preparations was prescribed in 69% in preference over the proprietary mononitrate preparations. This probably reflects the cost concern of the physicians in a developing country.
Background: Impedance cardiography is a non-invasive tool to estimate cardiac output and other hemodynamic parameters in critically ill patients. Methods: In order to characterize the hemodyamic profiles of patients with severe heart failure, impedance cardiography was performed in 13 patients with clinically stable heart failure (NYHA FC III-IV, ejection fraction 16+7%) and compared to 5 normal controls. All subjects were monitored twice using the IQ system model 101 (Renaissance Technology, Inc.). Hemodynamic parameters measured were cardiac index (CI, 1/m/m2), stroke volume (SV, ml), thoracic fluid volume (Zo) and acceleration index (ACI, sec 2) an estimate measurement of cardiac contractility. Results were as follows (mean + SD):
CI SV HR Zo ACI
NORMALS
HEART FAILURE
P VALUE
3.9+0.1 84+3 71223 29_+3 6.90_+0.6
2.44220.4 56226 87_+6 22+3 2.80+0.6
0.01 0.01 0.01 NS 0.01
The hemodynamic profile of patients with clinically stable severe heart failure is characterized by a lower cardiac index and stroke volume and a decreased contractility as evidenced by a lower acceleration index.
Conclusion: Impedance cardiography may be useful both to evaluate patients and assess the optimization of therapeutic interventions in severe heart failure.
194
195
Clinical Variables Predicting the Use of Beta-Blockers in Heart Failure: The BRING-UP Study P. Faggiano, M. Porcu, E. Balli, D. Lucci, M. Gorini, G. Fabbri, M. Scherillo, L. Tavazzi, A.P. Maggioni; ANMCO Research Center, Florence, Italy
Efficacy and Safety of Enhanced External Counterpulsation in Mild to Moderate Heart Failure: A Preliminary Report Ozlem Z. Soran, 1 Teresa DeMarco, 2 Lawrence E. Crawford, 1 Virginia Schneider,~ Paul-Andre de Lame) William Grossman, z Arthur M. Feldman~; ~Cardiology, University of Pittsburgh Medical Center, Pittsburgh, PA, ZCardiology, University of California San Francisco, San Francisco, CA, 3Anabase International Corp., Stockton, NJ
BRING-UP (BetablockeRs 1N patients with congestive heart failure: Guided Use in clinical Practice) is an observational study designed to guide the introduction of betablockers (BB) in the therapy of heart failure (HF) in the clinical practice of Italian cardiologists. The treatment (bisoprolol, carvedilol, metoprolol) was started according to the clinical decision of the responsible cardiologist. Out of 2975 pts enrolled in the study, 734 (24.7%) were already on BB: these pts were not included in the analysis. 836 (28.1%) staa~tedBB therapy, while 1405 (47.2%) did not. We analyzed the baseline characteristics of the pts receiving or not BB. NYHA IV class needing iv inotropes, hypotension, heart rate <50 bpm and/or hypokinetic arrhythmia, respiratory insufficiency and severe peripheral vasculopathy were considered absolute contraindications to BB therapy. At univariate analysis: (a) younger age, higher SBP and heart rate (HR), recent diagnosis of HF and a hystory of hypertension were significantly associated with a higher use of BB; (b) advanced (m-IV) NYHA class and atrial fibrillation were significantly associated with a lower use of BB; (c) gender, etiology, ejection fraction and history of diabetes did not influence BB prescription. At adjusted analysis the only variables that resulted independently associated with BB therapy are reported in the Table: Odds Ratio
95%
Age* SBP* HR* NYHA class III-IV vs I-II
0.968 1.017 1.013 0.601
CI
p
0.960-0.977 1.012-1.022 1.007-1.019 0.493-0.732
0.0001 0.0001 0.0001 0.0001
* as continuous variables Conclusions: In routine clinical practice cardiologists prescribe less frequently BB to patients with advanced age, low SBP, low HR and advanced NYHA class.
Enhanced external counterpulsation (EECP) is a non4nvasive therapy for symptomatic ischemic heart disease. By inflating sequentially 3 pairs of pneumatic cuffs wrapped around the legs and buttocks, EECP produces hemodynamic effects similar to those of intra-aortic balloon pumping, including increased diastolic and decreased systolic blood pressure, decreased afterload, and increased coronary perfusion. EECP has recentiy been shown to benefit patients with ischemic heart disease and anecdotal data suggest that it might be useful in patients with heart failure (HF). Thus, this study was initiated to assess formally the efficacy and safety of EECP in HF. Eligible patients had NYHA class II or III symptoms, an ejection fraction (LVEF) of 35% or less, and were clinically stable. Medical treatment was optimal according to accepted standards. The study intervention consisted of 35 1-hour EECP sessions over a 7-week period. Six subjects (mean age 61.3+ 11.2) were enrolled at 2 sites. The etiology of HF was ischemic cardiomyopathy in 5 patients and dilated idiopathic cardiomyopathy in 1 patient. Therapy began after a 2-week baseline assessment period. One subject discontinued after 21 sessions because of worsening back pain. Followmp data were obtained for all remaining subjects one week after the last EECP session. VO2max (ml/kg/min), the primary parameter, increased 18.7% from 13.63 221.54 (mean22SE) at baseline to 15.89+2.14 (p=0.004). Exercise duration (sec) increased 33.9% from 592.52296.26 to 756.0_ + 132.0 (p=0.008). All subjects were in NYHA class II at baseline. At follow-up, all but 1 subject were in NYHA class I. Quality of life score measured by the Minnesota Living with Heart Failure Questionnaire improved 35.3% (36.32210.2 at baseline to 22.3+6.0 after treatment). Clinical status remained stable in all study subjects during the application of EECP. Conclusion: These preliminary data, although limited, support the hypothesis that EECP may be efficacious and well tolerated in heart failure patients in the short term. Six-month follow-up data are being collected to document the long-term effect of this intervention in heart failure. The results need confirmation in a controlled trial.
•
HFSA
53
192
193
Prescription Patterns for Congestive Heart Failure in an Asian University Hospital Bernard W.K. Kwok, Tiong-Cheng Yeo, Boon-Lock Chia; Cardiac Department, National University Hospital, Singapore
Hemodynamic Profile of Patients with Severe Heart Failure by Impedance Cardiography Hector O. Ventura, Sherry J. Augustine, Yvonne B. Greenlee, Ibraiz Iqbal, Dwight D. Stapleton, Frank W. Smart; Tulane University Medical Center, New Orleans, LA
Recent studies have documented beneficial effects of beta-blockers, ACE-inhibitors and digoxin in patients with heart failure. To determine the prescription patterns in such patients, we did a retrospective analysis of all hospital admissions for congestive heart failure (ICD-9 Code 4280) in 1998. Of 635 admissions, 225 patients with LVEF -< 40% were identified (56% males, mean age 68 -- 25 years, range 36 to 98 years). The average hospital stay was 6 22 10 days. Aefiologies for heart failure were ischemic heart disease (77%), idiopathic dilated cardiomyopathy (16%), valvular heart disease (4%) and hypertensive heart disease (3%). Mean LVEF was 25 22 16 %. The prescription usage of the following drugs are:
ACE-inhibitors / Angiotensin-II antagonists diuretics nitrates hydrailazine digoxin beta-blockers spironolactone
81% 94% 72% 8% 64% 5% 5%
Despite recent literature documenting the beneficial effects of beta~blockers in congestive heart failure, we find that this class of drugs is under-prescribed. This perhaps reflects the reluctance or fear amongst physicians to embrace new knowledge, especially one that seems counterintuitive. In addition, we find that the commonest prescribed di'ug in each class was the lower cost generic ones. Captopril accounted for 69% of all ACE-inhibitors prescribed, while frusemide was the diuretic agent used in 90%. Generic dinitrate preparations was prescribed in 69% in preference over the proprietary mononitrate preparations. This probably reflects the cost concern of the physicians in a developing country.
Background: Impedance cardiography is a non-invasive tool to estimate cardiac output and other hemodynamic parameters in critically ill patients. Methods: In order to characterize the hemodyamic profiles of patients with severe heart failure, impedance cardiography was performed in 13 patients with clinically stable heart failure (NYHA FC III-IV, ejection fraction 16+7%) and compared to 5 normal controls. All subjects were monitored twice using the IQ system model 101 (Renaissance Technology, Inc.). Hemodynamic parameters measured were cardiac index (CI, 1/m/m2), stroke volume (SV, ml), thoracic fluid volume (Zo) and acceleration index (ACI, sec 2) an estimate measurement of cardiac contractility. Results were as follows (mean + SD):
CI SV HR Zo ACI
NORMALS
HEART FAILURE
P VALUE
3.9+0.1 84+3 71223 29_+3 6.90_+0.6
2.44220.4 56226 87_+6 22+3 2.80+0.6
0.01 0.01 0.01 NS 0.01
The hemodynamic profile of patients with clinically stable severe heart failure is characterized by a lower cardiac index and stroke volume and a decreased contractility as evidenced by a lower acceleration index.
Conclusion: Impedance cardiography may be useful both to evaluate patients and assess the optimization of therapeutic interventions in severe heart failure.
194
195
Clinical Variables Predicting the Use of Beta-Blockers in Heart Failure: The BRING-UP Study P. Faggiano, M. Porcu, E. Balli, D. Lucci, M. Gorini, G. Fabbri, M. Scherillo, L. Tavazzi, A.P. Maggioni; ANMCO Research Center, Florence, Italy
Efficacy and Safety of Enhanced External Counterpulsation in Mild to Moderate Heart Failure: A Preliminary Report Ozlem Z. Soran, 1 Teresa DeMarco, 2 Lawrence E. Crawford, 1 Virginia Schneider,~ Paul-Andre de Lame) William Grossman, z Arthur M. Feldman~; ~Cardiology, University of Pittsburgh Medical Center, Pittsburgh, PA, ZCardiology, University of California San Francisco, San Francisco, CA, 3Anabase International Corp., Stockton, NJ
BRING-UP (BetablockeRs 1N patients with congestive heart failure: Guided Use in clinical Practice) is an observational study designed to guide the introduction of betablockers (BB) in the therapy of heart failure (HF) in the clinical practice of Italian cardiologists. The treatment (bisoprolol, carvedilol, metoprolol) was started according to the clinical decision of the responsible cardiologist. Out of 2975 pts enrolled in the study, 734 (24.7%) were already on BB: these pts were not included in the analysis. 836 (28.1%) staa~tedBB therapy, while 1405 (47.2%) did not. We analyzed the baseline characteristics of the pts receiving or not BB. NYHA IV class needing iv inotropes, hypotension, heart rate <50 bpm and/or hypokinetic arrhythmia, respiratory insufficiency and severe peripheral vasculopathy were considered absolute contraindications to BB therapy. At univariate analysis: (a) younger age, higher SBP and heart rate (HR), recent diagnosis of HF and a hystory of hypertension were significantly associated with a higher use of BB; (b) advanced (m-IV) NYHA class and atrial fibrillation were significantly associated with a lower use of BB; (c) gender, etiology, ejection fraction and history of diabetes did not influence BB prescription. At adjusted analysis the only variables that resulted independently associated with BB therapy are reported in the Table: Odds Ratio
95%
Age* SBP* HR* NYHA class III-IV vs I-II
0.968 1.017 1.013 0.601
CI
p
0.960-0.977 1.012-1.022 1.007-1.019 0.493-0.732
0.0001 0.0001 0.0001 0.0001
* as continuous variables Conclusions: In routine clinical practice cardiologists prescribe less frequently BB to patients with advanced age, low SBP, low HR and advanced NYHA class.
Enhanced external counterpulsation (EECP) is a non4nvasive therapy for symptomatic ischemic heart disease. By inflating sequentially 3 pairs of pneumatic cuffs wrapped around the legs and buttocks, EECP produces hemodynamic effects similar to those of intra-aortic balloon pumping, including increased diastolic and decreased systolic blood pressure, decreased afterload, and increased coronary perfusion. EECP has recentiy been shown to benefit patients with ischemic heart disease and anecdotal data suggest that it might be useful in patients with heart failure (HF). Thus, this study was initiated to assess formally the efficacy and safety of EECP in HF. Eligible patients had NYHA class II or III symptoms, an ejection fraction (LVEF) of 35% or less, and were clinically stable. Medical treatment was optimal according to accepted standards. The study intervention consisted of 35 1-hour EECP sessions over a 7-week period. Six subjects (mean age 61.3+ 11.2) were enrolled at 2 sites. The etiology of HF was ischemic cardiomyopathy in 5 patients and dilated idiopathic cardiomyopathy in 1 patient. Therapy began after a 2-week baseline assessment period. One subject discontinued after 21 sessions because of worsening back pain. Followmp data were obtained for all remaining subjects one week after the last EECP session. VO2max (ml/kg/min), the primary parameter, increased 18.7% from 13.63 221.54 (mean22SE) at baseline to 15.89+2.14 (p=0.004). Exercise duration (sec) increased 33.9% from 592.52296.26 to 756.0_ + 132.0 (p=0.008). All subjects were in NYHA class II at baseline. At follow-up, all but 1 subject were in NYHA class I. Quality of life score measured by the Minnesota Living with Heart Failure Questionnaire improved 35.3% (36.32210.2 at baseline to 22.3+6.0 after treatment). Clinical status remained stable in all study subjects during the application of EECP. Conclusion: These preliminary data, although limited, support the hypothesis that EECP may be efficacious and well tolerated in heart failure patients in the short term. Six-month follow-up data are being collected to document the long-term effect of this intervention in heart failure. The results need confirmation in a controlled trial.