Daniel Krauss

Comparative Effects of Losartan and Enalapril on Exercise Capacity and Clinical Status in Patients With Heart Failure

OBJECTIVES This study was designed to determine 1) whether 12-week oral administration of losartan, an angiotensin II receptor antagonist, in patients with heart failure is well tolerated; and 2) whether functional capacity and clinical status of patients with heart failure in whom treatment with an angiotensin-converting enzyme (ACE) inhibitor is replaced with losartan for 12 weeks will remain similar to that noted in patients in whom treatment with an ACE inhibitor is continued. BACKGROUND Losartan is a specific, nonpeptide angiotensin II receptor antagonist. Although specific receptor blockade with losartan has certain theoretic advantages over nonspecific ACE inhibition, definitive demonstration of comparable effects in patients with congestive heart failure is lacking. METHODS A double-blind, multicenter, randomized, parallel, enalapril-controlled study was conducted in 116 patients with congestive heart failure (New York Heart Association functional classes II to IV) and left ventricular ejection fraction < or = 45% previously treated with stable doses of ACE inhibitors and diuretic agents, with or without concurrent digitalis and other vasodilators. After a baseline exercise period, open-label ACE inhibitors were discontinued, and patients were randomly assigned to 12 weeks of therapy with losartan, 25 mg/day (n = 38); losartan, 50 mg/day (n = 40); or enalapril, 20 mg/day (n = 38). Drug efficacy was evaluated by changes in maximal treadmill exercise time (using a modified Naughton protocol), 6-min walk test, left ventricular ejection fraction and dyspnea-fatigue index. Safety was measured by the incidence of clinical and laboratory adverse experiences. RESULTS The treadmill exercise time and the 6-min walk test did not change significantly after replacement of ACE inhibitor therapy with losartan. Similarly, a significant change was not observed in either the dyspnea-fatigue index or left ventricular ejection fraction at the end of double-blind period relative to baseline. CONCLUSIONS Losartan was generally well tolerated and comparable to enalapril in terms of exercise tolerance in this short-term (12-week) study of patients with heart failure. The clinical effects of long-term angiotensin II receptor blockade compared with ACE inhibition remain to be studied.

Cardiovascular complications of malignant carcinoid disease

Carcinoid tumors are endocrinologic malignancies often associated with a characteristic syndrome-the malignant carcinoid syndrome. Cardiovascular manifestations of this rare illness result from unique pathophysiologic characteristics, are associated with poor prognosis, and are difficult to treat medically. The hemodynamic consequences of this disease present unique management problems perioperatively. New pharmacologic and surgical therapies for malignant carcinoids have improved quality of life for patients to the extent that carcinoid heart disease now has more impact on morbidity and mortality rates. Cardiologists may be called on to diagnose and treat this rare cardiac disease. We review, for consulting cardiologists, the pathophysiologic characteristics, cardiovascular manifestations, and management of this disease.

Comparison of the Clinical Application of the American College of Cardiology Foundation/American Society of Echocardiography Appropriateness Criteria for Outpatient Transthoracic Echocardiography in Academic and Community Practice Settings

BACKGROUND We sought to compare the clinical application of the American College of Cardiology Foundation/American Society of Echocardiography Appropriateness Criteria (AC) for outpatient transthoracic echocardiography (TTE) in academic and community practice settings. METHODS Indications for TTE ordered in both academic and community practice settings were determined by 2 reviewers and categorized according to the AC for TTE as Appropriate, Inappropriate, or Not Addressed. Patient characteristics, ordering physician specialty, and TTE findings were also recorded. RESULTS Overall, 814 academic and 319 community TTEs were analyzed. Interobserver variability for indication determination was high and did not differ between studies ordered at the 2 practice settings. Compared with the academic practice, community practice TTE indications were more likely to be classified in the AC for TTE (88% vs 82%, P = .04), but were ordered for a similar frequency of Appropriate (71% vs 68%, P = not significant) and Inappropriate (17% vs 15%, P = not significant) indications. New important TTE abnormalities were more frequently found in Appropriate studies compared with Inappropriate studies in both academic (35% vs 16%, P < .001) and community practice (29% vs 15%, P = .04) settings. CONCLUSION The clinical application of the AC for TTE is feasible, and the frequency of Appropriate and Inappropriate outpatient TTEs is similar in academic and community practice settings. However, limitations of the AC for TTE are identified that suggest revisions will be needed to fully encompass and stratify the broad clinical practice of echocardiography.

Transnasal transesophageal echocardiography

Transesophageal echocardiography has been used as a diagnostic tool in the critical care unit. However, long-term serial evaluation of ventricular function with transesophageal echocardiography is difficult because of the current probe sizes and intolerance to prolonged oral intubation. We performed 139 intubations (64 oral and 75 transnasal) with a new prototype probe in 128 patients referred for transesophageal echocardiography. Transnasal intubation with the prototype probe was possible in 63/75 attempts. Oral intubation was successful in all 64 attempts. Patients tolerated transnasal intubation well when mildly sedated or awake. Two-dimensional echocardiographic views obtained with the nasal probe were similar to those obtained with a standard monoplane probe. Image quality was rated as good or acceptable in nearly all cases. Transgastric short-axis imaging of the left ventricle combined with acoustic quantification provided stable left ventricular area waveforms. Using custom developed software we showed the feasibility of monitoring left ventricular performance with minimal probe adjustment while graphically displaying and updating left ventricular area and fractional area change. Thus, transesophageal echocardiography with a prototype miniaturized monoplane probe passed transnasally is feasible, safe, and well tolerated by patients. This probe provides excellent two-dimensional echocardiographic images and may allow long-term echocardiographic monitoring of ventricular performance.

An echocardiographic approach to the assessment of aortic stenosis

An accurate echocardiographic assessment of aortic stenosis is critical for the cost-effective diagnosis and management of patients with the clinical suspicion of this diagnosis. Although the concepts involved in the echocardiographic determination of aortic pressure gradients and valve areas are relatively simple, acquisition of the data required to perform these calculations can at times be technically challenging. After reviewing the clinical signs and symptoms and the hemodynamics of aortic stenosis, this article reviews in detail the technical aspects involved in obtaining accurate gradients and valve areas emphasizing potential pitfalls.

Carcinoid Heart Disease

A53-year-old Indian man developed watery diarrhea. He was treated for inflammatory bowel disease without improvement. Three months before admission, he developed lower extremity edema, which progressed to include massive scrotal edema as well as dyspnea on exertion, orthopnea, and paroxysmal nocturnal dyspnea. An ECG (Fig 1⇓) and chest radiograph (Fig 2⇓) were performed. An upper gastrointestinal series and small bowel series were unrevealing. An abdominal computed tomography scan demonstrated the presence of multiple liver masses (Fig 3⇓). A percutaneous fine-needle liver biopsy was performed and yielded the cells seen in Fig 4⇓. A 24-hour urine collection for 5-hydroxyindoleacetic acid was markedly elevated at 871 μmol/d (normal, <200 μmol/d). Echocardiographic findings are summarized in Figs 5⇓ and 6⇓. Based on our findings (Figs 1 through …