Cardiovascular Disease: Heart Failure

Tuesday, November 10, 1998 Cardiovascular Disease: General, continued Results: Out of 135 patients \Vith resting heart rate 2:90, 85 r atients had an initial resting HR of 90-99 and 50 patients had an initia HR of 2:100. For both groups (135 patients), a total of 19 (14%) patients developed second or third degree AVB during AD infusion. In the former group (85 patients with HR 90- 99), 10 (12% ) developed second or third degree AVB comparing to 9 (18%) patients in latter group (50 patients with HR 2:100). No patients in either group had significant, symptomatic bradycardia or hypotension requiring treatment. Conclusions: In patients with resting heart rate 2:90 who underwent AD pharmacologic stress testing, the incidence of second and third degree AVB was 14%. In the group of patients with resting HR 90-99, the incidence was 12% comparing to 18% in the group with resting HR 2:100. No patients developed any significant, symptomatic bradycardia or hypotension requiring specific treatment. Clinical Implications: Adenosine pharmacologic stress testing in conjunction with radionuclide myocardial perfusion imaging can be used safely in patients with resting heart rate 2:90 for the evaluation of coronary arte•y disease and risk assessment.

Cardiovascular Disease: Heart Failure THE EFFECT OF PARTIAL LEFT VENTRICULECTOMY ON EXERCISE CAPACITY AND QUALITY OF LIFE IN PATIENTS WITH DILATED CARDIOMYOPATHY Eric Ten Brock, MD*; AEl-Solh, MD. M Miller, RRT. M Schnapp, RN. S Graham, MD. J P Houck, MD. B Grant, MD. Buffalo General Hospital, Buffalo, NY. Purpose: Early experience suggests that partial l eft ventriculectomy (PLV) improves cardiac function. We sought to assess the changes in exercise capacity and quality of life in patients with dilated cardiomyopathy after PLV, which have not been investigated yet. Methods: Seven patients in New York Heart Association functional class IV due to idiopathic cardiomyopathy (mean EF of 17.8 ~ 6.9) underwent PLV via median sternotomy. Symptom-limited cardiopulmonary exercise tests, 6-min walk distances (6MWD ), and sickness impact profile (SIP) scores were done before, and at 236~ 104 days. Results: All patients had significant improvements in 6MWD ((300.7 ~ 46.1 vs 457.1 ~ 100.1 m, p < 0.01 ). Overall SIP scores were lower (11.4 :!: 3.1 vs 20.64 :!: 4.2, p< 0.05 ) and was manifested in a decrease in both the physical dimension scores (3.6 :!: 1.3 vs 11.7 ~ 2.8, p<0.02) and the psychosocial dimension scores (9.7 :!: 2.3 vs 17.5 ± 2.96, p<0.005). On cardiopulmonary exercise testing, two patients showed improvement in oxygen uptake at peak exercise (8.9 :!: 0.8 vs 12.3 ± 1.2 mVkglmin), maximum oxygen pulse (7.5 ± 0.7 vs 9.5 ~ 0.8), maximum minute ventilation (44.05 ± 2.3 vs 48.8 :!: 2.8), and anaerobic threshold (28.5 ~ 4.2 vs 37.5 ± 3.8). This change was associated with comparable improvement in echocardiographic measurements co mpared to baseline. Conclusions: This study provides objective data that PLV is associated with improved quality of life and exercise endurance rather than maximal exercise capacity. Clinical Implications: PL V may prove to be a bridge or even an alternative to transplatation. THE EFFECT OF SPECIFIC INSPIRATORY MUSCLE TRAINING ON THE SENSATION OF DYSPNEA AND EXERCISE TOLERANCE IN PATIENTS WITH CONGESTIVE HEART FAILURE Paltiel Weiner, MD* ; J Waizman, MD. D Zamir, MD. R Magadle, MD. B Felled, MD. Departments of Medicine Aand Cardiology, Hillel Yaffe Medical Center, Hadera, Israel. Background and Aim: It has been previously shown that the inspiratory muscles of patients with congestive heart failure (CHF) are weaker than those of normal persons. This weakness may contribute to the dyspnea and limit exercise capacity in these patients. To evaluate the effect of specific inspiratory muscle training (SIMT) on inspiratory muscle performance, lung function , dyspnea and exercise capacity in patients with moderate heart failure. Patients and methods: 20 patients with CHF (NYHA junctional class II-III) were recruited for the study and were randomized into 2 groups: 10 patients consisted the study group and received SIMT and 10 patients were assigned to the control group and got sham training. Subjects in both

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groups trained daily, for 1/2 hour, 6 times/week, for 3 months. The subjects started breathing at a resistance equal to 15% of their PI max for one week and the resistance was then increased incrementally to 60%. Spirometry, inspiratory muscle strength (PI max at RV) and endurace (the relationship between PmPeak and Plmax), the 12-min walk test and peak V02 were performed before , and at the end of the training period. Results: All patients in the training group showed an increase in all the inspiratory muscle strength (mean Pimax increased from 46.5 ± 4.7 to 63.6:!:4.0 em H 20 , p<0.005), and endurance (mean PmPeak/Pimax from 47 . 8~3.6 to 67.7±1.7 %, p < 0.05) while it remained unchanged in the control group. This was associated with a small, but significant increase in FVC, a significant increase in the distance walked (458±29 to 562:!:32 m, p< 0.01 ) and an improvement in the dyspnea index score, in the training group. No statistically significant change in the mean peak V02 was noted in both groups. Conclusions: SIMT resulted in increased inspiratory muscle strength and endurance. This increase in inspiratory muscle performance was associated with decreased dyspnea, ni crease in submaximal exercise capacity. SIMT may prove to be a complimentary therapy in patients with CHF. THE EFFECT OF INTERMITTENT STIMULATION OF THE LATISSIMUS DORSI MUSCLE IN CARDIOMYOPLASTY M A Kashem*; BY Chiang. A Ali. AD Slater. LUnger. LA Gray. W P Santamore. Division of Thoracic and Cardiovascular Surgery, University of Louisville, Louisville, KY, USA. Purpose: Current continuous stimulation protocol of the latissimus dorsi muscle (LDM), following cardiomyoplasty (CMP) did not show expected results in the world data. We hypothesized that intermittent stimulation for the muscle preconditioning might play an important part in hemodynamic augmentation during systolic cardiac assistance by cardiomyoplasty. Methods: In mongrel dogs (n=6), LV dysfunction was induced by intracoronary injections of latex microspheres [90±2* diameter] and vascular delay procedure of the LDM was perfonned. After 2 weeks, a standard posterior CMP was performed followed b yprogressive intermittent preconditioning of the muscle (10 hours on/14 hours off, aday). After 9 weeks, LV fun ction was evaluated by assessing peak aortic pressure {AoP), left ventricular (LV) pressure, LV +dP/dt, LV -dP/dt, Stroke volume (SV), Stroke work (SW), Stroke power (SP), aortic flow (Qa). LDM stimulation caused significant increases of all hemodynamics in Cardiomyoplasty. LDM assisted beats (ST) were compared to nonstimulated beats (NS). Results: Table show the hemodynamic changes following LDM stimu lation in CMP, which are sustained increases and very different from the current world results. Also there were not significant changes in d iastolic properties after CMP. One hour continuous stimulation showed fatigue resistant muscle exhibiting no changes of the hemodynamics even after one hour. ST beats are significant when compared to NS beats (p<0.05). Conclusions: In this study, intermittent stimulation significantly augmented the hemodynami cs in Cardiomyoplasty without any muscle fatigability. It was concluded that current cardiomyoplasty protocols should consider intermittent stimulation of the skeletal muscle after the CMP surgery to avoid the overuse of the muscle, el ading to atrophy and fibrosis. Clinical Implications: Intermittent stimulation with vascular delay might change the current method, status and implication of cardiomyoplasty surgery in clinical settings. Table ST*

s

LVP

AoP

A. Flow

+dP/dt

-dP/dt

sv

113.9 ± 8.5* 113.4 ± 9.7* 13.5 ± 1.1 * 1804 ± 162* -1529 ± 132 25.6 ± 1.5* 96.0 ± 8.4 97.1 ± 9. 1 8.7 ± 0.6 1442 ± 242 -1315 ± 204 19.1 ± 0.8

sw

SP

Tau

PEP

ET

Total

Pep/ET

33.8 :!: 3.2*307.0 ± 35.4*34.0:!: 2.40.1 :!: 0.00.2 ± 0.00.3 ± 0.00.4 ± 0.0 21.3 ± 2.6 166.2 ± 25.9 42.3 ± 3.00.1 ± 0.00.3:!: 0.00.4 :!: 0.00.4 ± 0.1 Supported by: Partly supported by a Grant fran Jewish Heart and Lung ITistitute, University of Louisville, KY Abstracts of Original Investigations, CHEST 1998-Poster Presentations

Tuesday, November 10, 1998 Cardiovascular Disease: Heart Failure, continued RISK FACTOR CONTRIBUTIONS IN THE DEVELOPMENT OF CARDIO-PULMONARY DISEASE IN HISPANIC AND AFRICAN AMERICANS E. Guzman*; A P Niarchos. A Ansari. C Verghese. R Cohen. Division of Cardiology, Department of Medicine, Woodhull Medical & Mental Health Center, Brooklyn, New York. Purpose: The contribution of risk factors such as smoking, hypertension (HTN ), diabetes mellitus (DM ), ETOH abuse in the development of pulmonary and cardiovascular diseases in the different ethnic groups have been poorly studied. Hence we studied the differences in the contributory role of risk factors for obstructive pulmonary disease (OPD ) and/or congestive heart failure (CHF) between Hispanics (HA ) and African Americans (AA). Methods: 135 cases vvith OPD and CHF were randomly selected over a period of 2 years. They were analyzed for the prevalence of above risk factors. Obstructive Lung Disease + CHF Ejection fraction Vital Capacity* FEVl FEVl/FVC FVC

Obstructive Lung Disease 34 56 58 62 56

CHF 31%

65 46 57 50

70%

*% of predicted Results: 62% (N = 84) of the cases were HA (mean age 59 ::': 15 years) and 38% (N = 51) were AA (mean age 58 ::': 13 years). There was no significant difference in the prevalence of risk factors in the patients (pts) with obstructive pulmonary disease with or without CHF between HA and AA. However in pts \vith pure CHF (mean EF 30%) DM was more common in HA than AA (65% vs 37%, P < O.OOSil \vith Yates" correction). In AA with CHF, coronary arte1y disease (> 75% obstruction in one of the main coronary artery)) was more common (81 %AA vs 43 HA,.P < O.ol ). Conclusions: In HA DM probably plays a very important role in the development of CHF.

LEFT ATRIAL SYSTOLIC FUNCTION IN IDIOPATHIC AND ISCHEMIC DILATED CARDIOMYOPATHY: RESPONSE TO DOBUTAMINE STRESS Ioannis Moyssakis, MD*; F Triposkiadis, MD. T Doduras, MD. G Stavroulakis, MD. H Kasparian, MD. V Votteas, MD. T Makris, MD. M Kyriakidis, MD. Department of Cardiology, "Laikon" Hospital, University of Athens, Medical School, Athens, Greece. Purpose: Pathologic studies suggest left atrial (LA) involvement in the myopathic process in idiopathic (ID) dilated cardiomyopathy (DC). It was hypothesized that LA systolic response to Dobutamine stress (DabS) would differ between IDDC and ischemic (IS ) DC. Methods: Twenty six patients (pts) with IDDC and 28 with ISDC underwent symptom-limited DobS (5--40 J.Lg/Kglmin IV). LA volumes were echocardiographically determined at rest and peak stress at mitral valve (MV) opening (maximal, Vmax), electrocardiographic P wave (onset of atrial systole, Vp) and MV closure (minimal, Vmin ) from the apical 4and 2-chamber views (biplane area-length method). LA systolic function was assessed with the LA active emptying volume (ACTEV)= Vp-Vmin and fraction (ACTEF)= ACTEV/Vp. Results:

Vmax(cm 3 /m 2 ) rest peak stress ACTEV(cm·3fm 2 ) rest

IDDC

ISDC

p

54.2 ::': 12.0 54.5 ::': 13.4

48.5 ::': 18.0 48.8 ::': 19.0

NS NS

8.6 ::': 3.5

9.7 ::': 2.9

NS

peak stress ACTEF rest peak stress

IDDC

ISDC

7.2 ::': 3.6*

11.0 ::': 3.5

0.0003

0.33 ::': 0.08 0.36 ::': 0.17

0.0001 0.0001

0.20 ::': 0.1 0.17 ::': 0.9*

p

*p<0.05 vs rest Conclusions: Resting LA systolic function is depressed in IDDC compared to ISDC. LA systolic ejection during DabS deteriorates in IDDC and remains unaltered in ISDC. These findings suggest LA myopathy is IDDC.

SURVIVAL, MODES OF DEATH AND PROGNOSTIC FACTORS OF PATIENTS PRESENTING TO THE EMERGENCY DEPARTMENT WITH CONGESTIVE HEART FAILURE Humberto Villacorta, MD*; N Rocha, MD. T Bonates, MD. A C Silva, MD. H J Dohmann, PhD. E T Mesquita, PhD. Hospital Pro-Cardiaco, Rio de Janeiro, Brazil, and Universidade Federal Fluminense, Rio de Janeiro, Brazil. Purpose: We sought to determine the modes of death and the prognostic factors related to combined in-hospital and follow-up mortalities of patients with congestive heart failure (C HF) admitted to the emergency departm ent (ED) of a private tertiary hospital in Brazil. Methods: Seventy five consecutive patients were included between February 1996 and June 1997. Mean age was 72 ::': 15 (27 to 94) years and 49 (65,3%) were male. The most frequent etiology for CHF, combined or isolated, was coronary artery disease in 46 (6 1%) patients. We evaluated in-hospital evolution and prospectively assessed the out-hospital outcomes in a mean follow-up of 7.6 ::': 5 months. We evaluated the mode of death using the ACME system (Activity, Cause, Mode and Event), a new recently proposed classification for cardiac death. Results: In-hospital mortality was 15% (ll deaths). There were 14 (19%) deaths during follow-up. Modes of death were circulatory failure in 9 (64,5%) subjects, sudden death in 2 (14%) and peri-operative (mitral valve replacement, ventriculectomy and coronary artery bypass graft) in 3 (21,5%). Readmission rate was 53% in 7,6 months. Suvivial rates for 6, 12 and 16 months were 84%, 72%, and 60%, respectively. By multivariate analysis, only serum sodium less or equal to 135 mEq!l (p = 0,0008 ) was an independent predictor of mortality. Age (p = 0,0622 ) and femal e gender (p = 0,075 ) were of marginal statistical significance. Conclusions: In conclusion, patients with CHF admitted to the ED have high in-hospital and follow-up mortalities. Most of them die from circulatory failure due to the progression of CHF. Only serum sodium less or equal to 135 mEq/1 was an independent prognostic factor. Clinical Implications: Emergency physician can be able to identifY high-risk patients and treat them aggressively, since prognosis in CHF is bad.

LONG TERM SURVIVAL OF PATIENTS WITH CALCIFIED LEFT VENTRICULAR ANEURYSMS FOLLOWING MYOCARDIAL INFARCTIONS Nobuyuki Anzai, MD , FCCP*; 0 Sawatani, MD. Oyama Municipal Hospital, Oyama, Japan. Purpose: This study investigated long term survival of patients with calcified le ft ventricular aneurysms following myocardial infarctions (MI).

Methods: We followed 3 patients (pts), seen in our hospital over the last 10 years, with postinfarction calcified left ventlicular aneurysms. Clinical data, chest X-rays , ECGs, angiograms and CT chest scans were investigated. Results: Survival duration from MI to congestive heart failure (C HF): 16 (15-18) years, Age 75 (67-82), Male/Female 211. No patients experienced second Mls, and all were in good health prior to CHF onset. Chest X-rays revealed acalcified mass overlying the apical surface of the heart in all pts. ECGs revealed MI to be anterior in all pts. Left ventriculograms CHEST /114/4/ OCTOBER, 1998 SUPPLEMENT

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Tuesday, November 10, 1998 Cardiovascular Disease: Heart continued

Failure~

showed akinetic, nonexpandable left ventricular aneurysms at the apex. Coronary angiograms showed spontaneously reperfussed l eft anterior descending arteries (LAD) with slight stenotic lesions. Corona1y stenosis other than LAD and coronary artery collaterals were not seen. CT showed calcified ventricular aneUJysms protruding from the anterolateral surface of the left ventricles. Conclusions: These results suggest that the absence of coronary lesions other than the LAD, the lack of recurrent MI, and decreased aneurysm expansion due to calcium deposition into the wall of the aneurysm, may lead to longevity. Clinical Implications: Blood supply from spontaneously perfused LAD to the infarct zone may induce a solid necrotic zone, allo\ving for extensive calcification of th e aneurysm wall, that will decrease aneurys m expansion , which in turn may lead to prolonged life following an initial MI.

Cardiovascular Intervention/Diagnostics THE EFFECTS OF PARTIAL LEFT VENTRICULECTOMY ON EXERCISE CAPACITY AND QUALITY OF LIFE IN PATIENTS WITH DILATED CARDIOMYOPATHY. Eric Ten Brock, MD*; A AEl Solh, MD. M Miller, RRT. M S chnapp, RN. S Gral1am, MD. J P Houck, MD. BJ Grant, MD. Medicine, Buffalo General Hospital, Buffalo, NY, USA and Surge1y, Buffalo General Hospital, Buffalo, NY, USA. Purpose: Early experience suggests that partial left ventriculectomy (PLV) improves cardiac function. We sought to assess the changes in exercise capacity and quality of life in patients \vith dilated cardiomyopathy after PLV, which have not been investigated yet. Methods: Seven patients in New York Heart Association functional class IV due to idiopathic cardiomyopathy (mean EF of 17.8 ::t: 6.9) underwent PLV via median sternotomy. Symptom-limited cardiopulmonary exercise tests, 6-min walk distances (6M\VD), and sickness impact profile (SIP) scores were done before, and at 236::': 104 days. Results: All patients had significant improvements in 6MWD ((300.7 ::t: 46.1 vs 457.1 ::t: 100.1 m, p < 0.01 ). Overall SIP scores were lower (11.4 ::t: 3.1 vs 20.64 ::t: 4.2, p< 0.05 ) and was manifested in a decrease in both the physical dimension scores (3.6 ::t: 1.3 vs 11.7 ::t: 2.8, p< 0.02) and the psychosocial dimension scores (9.7 ::t: 2.3 vs 17.5 ::t: 2.96, p < 0.005 ). On cardiopulmonary exercise testing, two patients showed improvement in oxygen uptake at peak exercise (8.9 ::t: 0.8 vs 12.3 ::t: 1.2 ml!kglmin), maximum oxygen pulse (7.5 ::t: 0.7 vs 9.5 ::t: 0.8 ), maximum minute ventilation (44.05 ::t: 2.3 vs 48.8 ::t: 2.8), and anaerobic threshold (28.5 ::t: 4.2 vs 37.5 ::t: 3.8). This change was associated with comparable improvement in echocardiographic measurements compared to baseline. Conclusions: This study provides objective data that PLV is associated \vith improved quality of life and exercise endurance rather than maximal exercise capacity. Clinical Implications: PLV may prove to be a bridge or even an alternative to transplantation.

ventricular systolic function (LVEF) and acute procedural outcomes. Variables for acute procedural outcomes were angiographic success, cereberovascular accident (CVA), myocardial infarction (MI), CABG, death and others (i.e. arrhythmias, c~ronary dissections, abrupt closure, hematoma). Angiographic success was defined as residual stenosis el ss than 20%. Statistical analysis were performed using chi-square and t-test. Results: Four hundred and thirty one (58.8%) of 733 pts. were male and 302 (41.2%) female; 344 (47%) were White, 291 (40%) Black and 98 (13%) Hispanic. Female were older (63 vs 60 yrs; p< .003), more often had DM (38.7% vs 25.8%; p<.002), HTN (76.5% vs 62.6%; p<.001 ), functional class IV (35.8% vs 25.3%; p<.004) and were less often smokers (31.1% vs 58%, p<.001) than males. There were no differences for indications for PTCA, number of diseased v essels, LVEF, procedural success or complications. Whites were older (64 vs 59 and 49 yrs; p<.05) and more often smokers (53% vs 39% and 49%; p<.002) than Blacks and Hispanics. Hispanics more often had peripheral vascular disease (6.1% vs 2.7% and 1.5%; p<.03) than Blacks and Whites. Blacks and Hispanics more often had OM (38.8% and 38.8% vs 22.4%; p< .001), HTN (76% and 70% vs 61.1 %; p < .007) and no. of diseased vessels (1.62 and 1.67 vs 1.50: p=O.Ol) than Whites. There were no ethnic differences for indications for procedure , LVEF, procedural success, or overall complications. Conclusions: In this multiethnic population, although there are gender and race differences in coronary risk profile, there were no differences in acute procedural outcomes. Clinical Implications: Gender and race should not influence the revascularization strategy in pts. \vith CAD.

SAFETY AND EFFECTIVENESS OF PROPOFOL IN THE ELECTROPHYSIOLOGY (EP) LABORATORY Pramod M Deshmukh, MD*; H R Dib, MD. V G Harris, RN. P J He\vitt, RN. Guthrie Clinic, Ltd., Sayre, PA, USA. Purpose: To evaluate the safety and effectiveness of Propofol for sedation in the EP laboratory. Background: One or a combination of agents is used for sedation during electrophysiological (EP) procedures. Propofol is a sedative/ anesthetic that is not commonly used in non-intubated patients. Methods: Propofol was used as a sole sedative agent during 402 consecutive EP procedures. Infusion rate was 66.78 ::t: 36.50 mcglkglmin. to achieve sedation level III (asleep, but difficult to arouse). Average age was 69.38 ::t: 15.34 years. 02 saturation, BP and heart rate were monitored. Results: Twenty-one patients (5%) needed additional medication to achieve the required sedation level. All patients were amnestic to the procedure. None of the patients experienced nausea or vomiting. Both systolic (S) and diastolic (D ) blood pressure dropped significantly \vith Propofol infusion. (Table 1)

Pre-procedure: Post-procedure: *Difference: P-value

(S)

(D)

139.35 ::t: 25.50 117.73 ::t: 18.44 *21.62 ::t: 19.33 0.00

73.97 ::t: 14.53 64.18 ::t: 12.54 *9.78 ::t: 13.20 0.00

IMPACT OF GENDER AND RACE ON OUTCOME FOLLOWING CORONARY ANGIOPLASTY IN A MULTIETHNIC POPULATION Arshad M. Safi, MD* ; TW Kwan, MD. A F eit, MD. P Home!. L T Clark, MD. SUNY Health Science Center, Brooklyn, NY, USA.

*Differences were directly related to age, ie: higher age showed more significant drop.

Purpose: There islimited and conflicting data on the impacts of gender and race on patient (pts. ) outcomes following coronary angioplasty (PTCA). Accordingly, we analyzed the clinical profiles and outcomes of PTCA in a multiethnic inner city population. Methods: Seven hundred and thirty three consecutive pts. were enrolled who were undergoing elective coronary angioplasty, using the catheterization laboratory data base. Pts. >vith acute myocardial infarction requiring primary PTCA were excluded form the study. The following variables were retrospectively analyzed: age, sex, race, hypertension (HTN), smoking, diabetes mellitus (DM), family history, peripheral vascular disease, history of prior PTCA I CABG, angioplasty vessel, left

One patient required intubation due to pulmonary edema. Another patient needed vasopressors after malignant arrhythmias. No patient required h emodynamic intervention as a result of sedation. Conclusions: Deep sedation during EP procedures in non-intubated patients can be achieved effectively and safely by the use of Propofol solely or with a combination of other sedative agents . Propofol caused statistically significant, but clinically irrelevant, decrease in systolic and diastolic blood pressure. Clinical Implications: Propofol is another sedative agent that could be used in the EP laboratory.

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Abstracts of Original Investigations, CHEST 1998-Poster Presentations