Ajit K. Agarwal

Prevalence and aetiology of heart failure in an Arab population

The epidemiology of heart failure in Arabia, with a population different from the West in cultural and ethnic origin, has not been studied before.

Beneficial effect of carvedilol on heart rate response to exercise in digitalised patients with heart failure in atrial fibrillation due to idiopathic dilated cardiomyopathy.

Fourteen digitalised patients diagnosed with heart failure (NYHA Functional class II) with idiopathic dilated cardiomyopathy in chronic established atrial fibrillation were administered carvedilol in addition to their anti‐heart failure medications in an attempt to improve their heart rate control. Fourteen matched patients who did not receive carvedilol acted as control subjects. Patients treated with carvedilol showed significantly reduced resting heart rates (10–36%), maximal heart rates on exercise (5–20%) and an increased exercise time (2–30%) on treadmill stress tests (all P ‐ 0.001). Ventricular ectopic activity was also diminished. This was associated with symptomatic improvement in effort intolerance and palpitations. NYHA functional class, left ventricular dimensions and ejection fractions did not improve during the study period of 3 months. Thus, addition of carvedilol to digoxin had a beneficial effect on exercise tolerance in patients with idiopathic dilated cardiomyopathy in atrial fibrillation by virtue of an improved heart rate control both at rest and on exercise. Carvedilol was well tolerated despite impaired myocardial function.Fourteen digitalised patients diagnosed with heart failure (NYHA Functional class II) with idiopathic dilated cardiomyopathy in chronic established atrial fibrillation were administered carvedilol in addition to their anti-heart failure medications in an attempt to improve their heart rate control. Fourteen matched patients who did not receive carvedilol acted as control subjects. Patients treated with carvedilol showed significantly reduced resting heart rates (10-36%), maximal heart rates on exercise (5-20%) and an increased exercise time (2-30%) on treadmill stress tests (all P=0.001). Ventricular ectopic activity was also diminished. This was associated with symptomatic improvement in effort intolerance and palpitations. NYHA functional class, left ventricular dimensions and ejection fractions did not improve during the study period of 3 months. Thus, addition of carvedilol to digoxin had a beneficial effect on exercise tolerance in patients with idiopathic dilated cardiomyopathy in atrial fibrillation by virtue of an improved heart rate control both at rest and on exercise. Carvedilol was well tolerated despite impaired myocardial function.

Plasma catecholamine levels parallel severity of heart failure and have prognostic value in children with dilated cardiomyopathy

Excessive and sustained sympathetic stimulation favours progression of heart failure, and plasma catecholamine estimation can assess the degree of this stimulation w1x. High plasma noradrenaline levels have been reported in children with heart failure but these studies have largely included patients with congenital and valvular heart diseases w2–4x. We studied plasma catecholamine levels in children with chronic heart failure from idiopathic dilated cardiomyopathy(IDC), and related these to the severity of heart failure and outcome.

Chronic cardiac failure in children due to dilated cardiomyopathy: diagnostic approach, pathophysiology and management.

Abstract Dilated cardiomyopathy (DCM) is an important cause of chronic congestive cardiac failure (CCF) in infants and children. Although a variety of aetiological factors have been listed, most patients with echocardiographically documented DCM do not possess a demonstrable cause. Poor myocardial function in DCM triggers a sequence of compensatory mechanisms, mediated through the renin angiotensin system, the sympathetic system (neural and humoral) and a number of vasodilatory molecules. These favour myocardial and peripheral vascular remodelling by necrosis, fibrosis and apoptosis which ultimately does more harm than good. Management is essentially similar to that of CCF using a combination of diuretics, angiotensin converting enzyme inhibitors (ACEI) and digoxin. Use of additional diuretics, intravenous frusemide, dobutamine infusion and β-adrenergic receptor blockers help to improve quality of life in resistant patients. ACEI, β-adrenergic blockers and possibly aldosterone antagonists prolong survival. Compliance to medication can be enhanced by improving drug formulations and by assisting the family to choose the ‘best-fit’ regimen (concordance). At present, optimum management of end-stage CCF is cardiac transplant. Conclusion Current understanding of the pathophysiology of chronic congestive cardiac failure resulting from dilated cardiomyopathy has shifted management strategy from steps that directly improve myocardial function to those that modulate the neuroendocrine profile and peripheral vascular reactivity. Similar advances in therapeutic applications would be assisted by controlled studies and full licensing of drugs for use in children. Medical intervention will remain the cornerstone of management until advances in surgical techniques become more widely available.

Catecholamine levels in heart failure due to dilated cardiomyopathy and their relationship to the severity of heart failure

Persistent sympathetic stimulation, a major factor responsible for continuing myocardial injury and worsening chronic heart failure due to idiopathic diŽ . lated cardiomyopathy IDC , is reflected in raised plasma catecholamine levels. Raised noradrenaline levels quantify the sympathetic response and have w x been reported to be of prognostic value 1,2 . Therapy w x with beta-blockade improves outcome 3 . Recently, Richards et al. have demonstrated elevated levels of atrial natriuretic peptide, brain natriuretic peptide Ž . BNP andror noradrenaline in heart failure. In nearly a quarter of their study patients having supramedian BNP but inframedian levels of noradrenaline, carvedilol was able to reduce the hospital admission w x rate for heart failure significantly 4 .

Deep upper limb and jugular venous thrombosis in dilated cardiomyopathy.

1 Carlin BI, Resnick MI. Indications and techniques for urologic evaluation of the trauma patient with suspected urologic injury. Semin Urol 1995;13:9-24 2 Davenport A, Goldsmith HJ. Ruptured bladder presenting as acute renal failure. BrJ Hosp Med 1989;41:579-80 3 Dees A, Kluchert SA, van Vliet ACM. Pseudo-renal failure with intestinal leakage of urine. NethJ Med 1990;37:197-201 4 Peters PC, Sagalowsky Al. Genitourinary trauma. In: Walsh PC, Gittes RF, Perlmutter AD, Stamey TA, eds. Campbells Urology. London: WB Saunders, 1986:1191-246 5 Mullkey AP, Witherington R. Conservative management of vesical rupture. Urology 1974;4:426-30

Low proportion of familial dilated cardiomyopathy in an Arab population with a high prevalence of consanguineous marriages

In this study, 770/890 (87%) first‐degree relatives from 108 families of hospitalized patients with idiopathic dilated cardiomyopathy (IDC) were screened using clinical examination, electrocardiography and echocardiography. Thirty percent of the patients were born to consanguineous parents. Familial dilated cardiomyopathy (FDC) was found in 7 (6.5%) families, which is lower than the earlier published figures of 20‐25%. Patients with IDC were younger at presentation (p= 0.002) and were more often associated with parental consanguinity (p= 0.04), but the survival rates of familial patients did not differ significantly.

A rare form of atrioventricular septal defect with severe subaortic stenosis.

An unusual form of atrioventricular septal defect associated with severe subaortic obstruction is reported in a neonate who presented with intractable cardiac failure. The baby had a large defect in the atrioventricular septum allowing communication from the left ventricle to the right atrium, without interatrial or interventricular communication, and a cleft anterior mitral leaflet. The baby expired despite palliative surgery performed to bypass the subaortic stenosis.