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The management of chronic heart failure
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LITERATURE REVIEW
and $35,700 without PAC. The mean length of ICU stay was 14.8 days with PAC and 13.0 days without PAC. Subgroup analysis did not show any patient group for which PAC was associated with improved outcome. Patients with higher baseline probability of surviving 2 months had the highest relative risk of death after PAC. These findings may not be explained by the fact that PAC-treated patients were sicker. Sensitivity analysis suggested that a missing covariate (ie, an unknown index of sickness) would have to increase the risk of death threefold to reduce the true relative hazard of pulmonary artery catheterization to 1.0. This analysis creates enough uncertainty about the value of pulmonary artery catheterization in the patients studied to warrant reevaluation of this diagnostic modality in this nonsurgical population. REVIEW ARTICLES
Verrier ED, Boyle Jr EM: Endothelial cell injury in cardiovascular surgery. Ann Thorac Surg 62:915-922, 1996 Vascular endothelial role in the regulation of membrane permeability, lipid transport, vasomotor tone, coagulation, fibrinolysis, and inflammation is discussed in this brief review. Expression of endothelialderived biologically active surface proteins or secreted soluble factors that exert opposing effects on vasomotion, coagulation, platelet and leukocyte adhesion, and arterial wall morphology is altered by disease and cardiac surgery-related injury. The role of neutrophil-endothelial cell interaction in the whole body inflammatory response to cardiopulmonary bypass, ischemia/reperfusion injury, and organ preservation is highlighted.
Cohn JN: The management of chronic heart failure. N Engl J Med 335:490-498, 1996 Because the symptoms of heart failure are only weakly related to the severity of left ventricular dysfunction and mortality, treatment of heart failure entails strategies to retard the progression of left ventricular dysfunction as well as to relieve symptoms. Relief of symptoms is achieved by restriction of salt intake, thiazide and loop diuretics, vasodilators, and digoxin. In a recently completed clinical trial involving more than 7,500 patients, digoxin was observed to have no effect on mortality but reduced the rate of hospitalization as compared with that for placebo-treated patients. Strategies to prolong lives of patients with left ventricular dysfunction include restriction of alcohol consumption and therapy with angiotensin-converting enzyme inhibitors, hydralazine, and isosorbide dinitrate. The value of chronic anticoagulation has not yet been documented. Antiarrhythmic therapy, coronary revascularization, and cardiomyoplasty may offer benefits to specific patients. Brief references are made to new approaches with [3-adrenergic antagonists, calcium antagonists, vesnarinone, and neurohumoral inhibitors. Milrinone and xamoterol, inotropic agents, have been found to have an adverse effect on mortality.
ACKNOWLEDGMENT
The reports reviewed in this issue were selected from those published in the following journals: Annals of Internal Medicine, Annals of Thoracic Surgery, Journal of the American Medical Association, Journal of Thoracic and Cardiovascular Surgery, and the New England Journal of Medicine.
LITERATURE REVIEW
and $35,700 without PAC. The mean length of ICU stay was 14.8 days with PAC and 13.0 days without PAC. Subgroup analysis did not show any patient group for which PAC was associated with improved outcome. Patients with higher baseline probability of surviving 2 months had the highest relative risk of death after PAC. These findings may not be explained by the fact that PAC-treated patients were sicker. Sensitivity analysis suggested that a missing covariate (ie, an unknown index of sickness) would have to increase the risk of death threefold to reduce the true relative hazard of pulmonary artery catheterization to 1.0. This analysis creates enough uncertainty about the value of pulmonary artery catheterization in the patients studied to warrant reevaluation of this diagnostic modality in this nonsurgical population. REVIEW ARTICLES
Verrier ED, Boyle Jr EM: Endothelial cell injury in cardiovascular surgery. Ann Thorac Surg 62:915-922, 1996 Vascular endothelial role in the regulation of membrane permeability, lipid transport, vasomotor tone, coagulation, fibrinolysis, and inflammation is discussed in this brief review. Expression of endothelialderived biologically active surface proteins or secreted soluble factors that exert opposing effects on vasomotion, coagulation, platelet and leukocyte adhesion, and arterial wall morphology is altered by disease and cardiac surgery-related injury. The role of neutrophil-endothelial cell interaction in the whole body inflammatory response to cardiopulmonary bypass, ischemia/reperfusion injury, and organ preservation is highlighted.
Cohn JN: The management of chronic heart failure. N Engl J Med 335:490-498, 1996 Because the symptoms of heart failure are only weakly related to the severity of left ventricular dysfunction and mortality, treatment of heart failure entails strategies to retard the progression of left ventricular dysfunction as well as to relieve symptoms. Relief of symptoms is achieved by restriction of salt intake, thiazide and loop diuretics, vasodilators, and digoxin. In a recently completed clinical trial involving more than 7,500 patients, digoxin was observed to have no effect on mortality but reduced the rate of hospitalization as compared with that for placebo-treated patients. Strategies to prolong lives of patients with left ventricular dysfunction include restriction of alcohol consumption and therapy with angiotensin-converting enzyme inhibitors, hydralazine, and isosorbide dinitrate. The value of chronic anticoagulation has not yet been documented. Antiarrhythmic therapy, coronary revascularization, and cardiomyoplasty may offer benefits to specific patients. Brief references are made to new approaches with [3-adrenergic antagonists, calcium antagonists, vesnarinone, and neurohumoral inhibitors. Milrinone and xamoterol, inotropic agents, have been found to have an adverse effect on mortality.
ACKNOWLEDGMENT
The reports reviewed in this issue were selected from those published in the following journals: Annals of Internal Medicine, Annals of Thoracic Surgery, Journal of the American Medical Association, Journal of Thoracic and Cardiovascular Surgery, and the New England Journal of Medicine.