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Diuretic effects of phosphodiesterase inhibitors depend on baseline renal function in patients with heart failure
The 2nd Annual Scientific Meeting
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JHFS
138
LEFT VENTRICULAR CONTRACTILE RESERVE AS A PREDICTOR OF THE PROGNOSIS IN PATIENTS WITH CHRONIC HEART FAILURE
CARDIAC FAILURE COMPLICATED WITH ACUTE MYOCARDIAL INFARCTION WAS IMPROVED BY NOT DOBUTAMINE BUT MILRINONE : A CASE REPORT
Masahiro Ito, Kazuyuki Ozaki, Yoshinori Aoki, Yuuji Okura, Yuichi Nakamura, Takashi Washizuka, Haruo Hanawa, Makoto Kodama, Yoshifusa Aizawa The 1st department of internal medicine, Niigata University School of Medicine, Niigata 951-8510, Japan
Takashi Iwase, Shinichiro Nishiyama,Yutaro Nishi, Shigemoto Nakanishi, Shinichi Momomura, Division of Cardiology,Cardiovascular Center,Toranomon Hospital, Tokyo 105-8470,Japan
In patients with chronic heart failure, various approaches have been proposed to assess the prognosis but it remains a unresolved clinical problem. The relationship between the long-term prognosis and the left ventricular inotropic and lusitropic reserves under stepwise dobutamine (DOB) loading was assessed in 48 patients (mean age 52) with chronic heart failure. Underling heart diseases consisted of idiopathic dilated cardiomyopathy, post-myocarditis cardiomyopathy and hypertensive heart disease. During cardiac catheterization, /5'adrenoceptor stimulation was performed using intravenous DOB infusion in the stepwise doses of 2"y, 4?" and 8?'. Responses of the left ventricular contractility and relaxation were measured by the left ventricular peak positive dp/dt and the peak negative dp/dt. Changes of the cardiac index were also analyzed. Echocardiographic (UCG) parameters, namely LVEDd, LVESd and FS were serially obtained during follow up period. Patients were treated using diuretics, digoxin, ACE inhibitors and ,B-blockers. After a mean follow-up period of 5.6 years, 9 patients died (18%), but no patients whose response of dp/dt at 4?" of DOB exceeded 40% over the basal value have been died. Adp/dt and the changes of UCG parameters were not related to the prognosis. A-dp/dt and AC.I also had no relationships with prognosis and change of cardiac function. In conclusion, patients with chronic heart failure whose dp/dt can respond over 40% in 4 ?" of DOB had good prognosis.
139 DIURETIC EFFECTS OF PHOSPHODIESTERASE INHIBITORS DEPEND ON BASELINE RENAL FUNCTION IN PATIENTS WITH HEART FAILURE
Munetake Kanda, Satoshi Yasuda, Yoichi Goto, Hitoshi Sumida, Takeshi Baba, Teruo Noguchi, Hiroshi Nonogi Division of Cardiology, National Cardiovascular Center, Osaka 565-0873 Phosphodiesterase inhibitors (PDE-I) have both positive inotropic and vasodilating effects to increase cardiac output and renal blood flow, facilitating diuresis in patients (pts) with heart failure (HF). On the contrary, a decrease in renal perfueion pressure due to vasodilating effects of PDE-I may be potentially detrimental to diuresis in p:ts with HF and concomitant renal failure. To test this hypothesis, we studied 11 pts with HF who were treated with PDE-]. Pts were divided into 2 groups without (N group of 5 pts) and with renal failure (serum creatinine > 2.0 mg/dL: F group of 6 pts). Mean pulmonary capillary wedge pressure (PCm), cardiac index (CI) and averaged urine volume per hour (UV) were determined before and after PDE-I. Results: Before PDE-I, there were no differences in PCm (N: 28+_9vs F: 25_+5 mmHg, mean_+SD) or CI (N: 2.0__.0.5vs F: 2.0_*-0.9 L/m2) between the 2 groups. PDE-I decreased PCm (N: 17±10 vs F: 19-_6) and increased CI (N: 2.7-+-0.9 vs F: 2.7±0.6) to similar extents. Nevertheless, renal responses were completely different : UV increased (from 36±28 to 145_+67 mL/hr, +462%) in group N, whereas decreased (from 70+_20 to 53_+37 mL/hr, -22%, P<0.01 vs grOup N) in group F. C o n c l u s i o n s : Despite the improvement in central hemodynamics, PDE-I do not necessarily facilitate diuresis in HF pts with concomitant renal failure. The application of PDE-I for these pts should be cautious.
A 76-year-old woman with a past medical history only for diabetes mellitus was admitted to our hospital because of severe dyspnea. Her ECG revealed RBBB and lmm of ST elevation in precordial leads V1 through V4 consistent with an acute anteroseptal myocardial infarction. Her WBC,serum Cr, BUN,CK,AST and LDH level were 9800 /fz 1,1.5 mg/dl,50 mg/dl,304 IU/I,58 IU/I,826 IU/I,respectively. Chest X ray demonstrated cardiomegaly,bilateral pleural effusion,right sided pulmonary congestion and alrbronchogram consistent with pneumonia.Blood gas analysis ( BGA ) sampled at room air demonstrated severe hypoxemia with 42 torr of PaO2. Cardiac index and pulmonary capillary wedge pressure were 2.7 l/min/m2 and 16 mmHg on condition of 3 ~r of dobutamine administration. Furosemide,lsosorbide dinitrate, dobutamine and antibiotics could not improve her symptom, chest X ray findings and BGA data. So,0.3 r of Milrinone was started to on the 10th day of admission.It was very effective for relief of her dyspnea and improvement of her chest X ray findings and blood gas analysis data. Milrinone has unique actions of vasodilatation and increase of cardiac contractility. We concluded that the vasodilating action of Milrinine on pulmonary arteries resulted in improvement of cardiac failure complicated with acute myocardial infarction.
140 MILRINONE DOES NOT SHOW SALUTARY EFFECTS ON SYSTEMIC HEMODYNAMICS IN ALL PATIENTS WITH POOR BASELIN1); LEFI" VENTR!CULAR FUNCTION Daisaku Nakatani, Young--Jae IJm, On Fukui, Shigeo Kawano, Masayoshi Mishima KAWACHI GENERAL HOSPIT \L, OSAKA, JAPAN To assess the effects of i.v. mii:~none (MID on systemic herno-dynamics and left ventricular (LV) function in patients with myocardial infarction in chronic stage. Studied were 14 patients w i t h poor LV ejection fraction (< 40%). Bolus (50 m g / k g body weigh[ over i0 n~.in) and continuous infusion (0.5 # g / k g / m i n for 15 rain) of MIL was administered. Intravenous MIL resulted in ma rke d decrease in aortic pressure (< 100 mmHg) accompanied by some decrease in cardiac output in 7 patients (Group A), bt,t ~o suc.h a h e m o - d y n a m i c exacerbation in other 7 [~atients (Group B). No significant differences in baseline systemic hemodynamics w e re observed between the 2 groups. RESULTS: During MIL infusion, HR (81_~8 , 9 0 ± 1 2 and 85_+ 18~97_+25bpm in Group A and B, respectively) increased and LVEF (35_+ 10 42-+8 and 35 _+18 ~39 ± i8 %) improved in similar extent in both groups. The greater preload reduction in LVEDP (9.3_+ 2.0 + 6.3_+1.0 and 8.3 _+0.5~7.0_+3.0 mmHg. p< .05) and LVEDVI (65 ± 14 -, 52_+ ! i and 66 -+ 19~ 59 _+18 m l / m e, p< .05) was observed in Group A tha~ in Group B. In Group A, 5 patients showed antero -apical dyskinesis and only in 2 patients with dysldnesis of small apical area. CONCLUSION: Careful he modyna mi c observation is necessary during the administration of milrinone, especiaIly in patients w i t h broad myocardial infarction and anteroapicat dyskinesis.
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137
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JHFS
138
LEFT VENTRICULAR CONTRACTILE RESERVE AS A PREDICTOR OF THE PROGNOSIS IN PATIENTS WITH CHRONIC HEART FAILURE
CARDIAC FAILURE COMPLICATED WITH ACUTE MYOCARDIAL INFARCTION WAS IMPROVED BY NOT DOBUTAMINE BUT MILRINONE : A CASE REPORT
Masahiro Ito, Kazuyuki Ozaki, Yoshinori Aoki, Yuuji Okura, Yuichi Nakamura, Takashi Washizuka, Haruo Hanawa, Makoto Kodama, Yoshifusa Aizawa The 1st department of internal medicine, Niigata University School of Medicine, Niigata 951-8510, Japan
Takashi Iwase, Shinichiro Nishiyama,Yutaro Nishi, Shigemoto Nakanishi, Shinichi Momomura, Division of Cardiology,Cardiovascular Center,Toranomon Hospital, Tokyo 105-8470,Japan
In patients with chronic heart failure, various approaches have been proposed to assess the prognosis but it remains a unresolved clinical problem. The relationship between the long-term prognosis and the left ventricular inotropic and lusitropic reserves under stepwise dobutamine (DOB) loading was assessed in 48 patients (mean age 52) with chronic heart failure. Underling heart diseases consisted of idiopathic dilated cardiomyopathy, post-myocarditis cardiomyopathy and hypertensive heart disease. During cardiac catheterization, /5'adrenoceptor stimulation was performed using intravenous DOB infusion in the stepwise doses of 2"y, 4?" and 8?'. Responses of the left ventricular contractility and relaxation were measured by the left ventricular peak positive dp/dt and the peak negative dp/dt. Changes of the cardiac index were also analyzed. Echocardiographic (UCG) parameters, namely LVEDd, LVESd and FS were serially obtained during follow up period. Patients were treated using diuretics, digoxin, ACE inhibitors and ,B-blockers. After a mean follow-up period of 5.6 years, 9 patients died (18%), but no patients whose response of dp/dt at 4?" of DOB exceeded 40% over the basal value have been died. Adp/dt and the changes of UCG parameters were not related to the prognosis. A-dp/dt and AC.I also had no relationships with prognosis and change of cardiac function. In conclusion, patients with chronic heart failure whose dp/dt can respond over 40% in 4 ?" of DOB had good prognosis.
139 DIURETIC EFFECTS OF PHOSPHODIESTERASE INHIBITORS DEPEND ON BASELINE RENAL FUNCTION IN PATIENTS WITH HEART FAILURE
Munetake Kanda, Satoshi Yasuda, Yoichi Goto, Hitoshi Sumida, Takeshi Baba, Teruo Noguchi, Hiroshi Nonogi Division of Cardiology, National Cardiovascular Center, Osaka 565-0873 Phosphodiesterase inhibitors (PDE-I) have both positive inotropic and vasodilating effects to increase cardiac output and renal blood flow, facilitating diuresis in patients (pts) with heart failure (HF). On the contrary, a decrease in renal perfueion pressure due to vasodilating effects of PDE-I may be potentially detrimental to diuresis in p:ts with HF and concomitant renal failure. To test this hypothesis, we studied 11 pts with HF who were treated with PDE-]. Pts were divided into 2 groups without (N group of 5 pts) and with renal failure (serum creatinine > 2.0 mg/dL: F group of 6 pts). Mean pulmonary capillary wedge pressure (PCm), cardiac index (CI) and averaged urine volume per hour (UV) were determined before and after PDE-I. Results: Before PDE-I, there were no differences in PCm (N: 28+_9vs F: 25_+5 mmHg, mean_+SD) or CI (N: 2.0__.0.5vs F: 2.0_*-0.9 L/m2) between the 2 groups. PDE-I decreased PCm (N: 17±10 vs F: 19-_6) and increased CI (N: 2.7-+-0.9 vs F: 2.7±0.6) to similar extents. Nevertheless, renal responses were completely different : UV increased (from 36±28 to 145_+67 mL/hr, +462%) in group N, whereas decreased (from 70+_20 to 53_+37 mL/hr, -22%, P<0.01 vs grOup N) in group F. C o n c l u s i o n s : Despite the improvement in central hemodynamics, PDE-I do not necessarily facilitate diuresis in HF pts with concomitant renal failure. The application of PDE-I for these pts should be cautious.
A 76-year-old woman with a past medical history only for diabetes mellitus was admitted to our hospital because of severe dyspnea. Her ECG revealed RBBB and lmm of ST elevation in precordial leads V1 through V4 consistent with an acute anteroseptal myocardial infarction. Her WBC,serum Cr, BUN,CK,AST and LDH level were 9800 /fz 1,1.5 mg/dl,50 mg/dl,304 IU/I,58 IU/I,826 IU/I,respectively. Chest X ray demonstrated cardiomegaly,bilateral pleural effusion,right sided pulmonary congestion and alrbronchogram consistent with pneumonia.Blood gas analysis ( BGA ) sampled at room air demonstrated severe hypoxemia with 42 torr of PaO2. Cardiac index and pulmonary capillary wedge pressure were 2.7 l/min/m2 and 16 mmHg on condition of 3 ~r of dobutamine administration. Furosemide,lsosorbide dinitrate, dobutamine and antibiotics could not improve her symptom, chest X ray findings and BGA data. So,0.3 r of Milrinone was started to on the 10th day of admission.It was very effective for relief of her dyspnea and improvement of her chest X ray findings and blood gas analysis data. Milrinone has unique actions of vasodilatation and increase of cardiac contractility. We concluded that the vasodilating action of Milrinine on pulmonary arteries resulted in improvement of cardiac failure complicated with acute myocardial infarction.
140 MILRINONE DOES NOT SHOW SALUTARY EFFECTS ON SYSTEMIC HEMODYNAMICS IN ALL PATIENTS WITH POOR BASELIN1); LEFI" VENTR!CULAR FUNCTION Daisaku Nakatani, Young--Jae IJm, On Fukui, Shigeo Kawano, Masayoshi Mishima KAWACHI GENERAL HOSPIT \L, OSAKA, JAPAN To assess the effects of i.v. mii:~none (MID on systemic herno-dynamics and left ventricular (LV) function in patients with myocardial infarction in chronic stage. Studied were 14 patients w i t h poor LV ejection fraction (< 40%). Bolus (50 m g / k g body weigh[ over i0 n~.in) and continuous infusion (0.5 # g / k g / m i n for 15 rain) of MIL was administered. Intravenous MIL resulted in ma rke d decrease in aortic pressure (< 100 mmHg) accompanied by some decrease in cardiac output in 7 patients (Group A), bt,t ~o suc.h a h e m o - d y n a m i c exacerbation in other 7 [~atients (Group B). No significant differences in baseline systemic hemodynamics w e re observed between the 2 groups. RESULTS: During MIL infusion, HR (81_~8 , 9 0 ± 1 2 and 85_+ 18~97_+25bpm in Group A and B, respectively) increased and LVEF (35_+ 10 42-+8 and 35 _+18 ~39 ± i8 %) improved in similar extent in both groups. The greater preload reduction in LVEDP (9.3_+ 2.0 + 6.3_+1.0 and 8.3 _+0.5~7.0_+3.0 mmHg. p< .05) and LVEDVI (65 ± 14 -, 52_+ ! i and 66 -+ 19~ 59 _+18 m l / m e, p< .05) was observed in Group A tha~ in Group B. In Group A, 5 patients showed antero -apical dyskinesis and only in 2 patients with dysldnesis of small apical area. CONCLUSION: Careful he modyna mi c observation is necessary during the administration of milrinone, especiaIly in patients w i t h broad myocardial infarction and anteroapicat dyskinesis.
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